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Daniel Castellanos, MD Medical Director, South Florida Behavioral Health Network SFBHN Psychotropic Medications Training 2014

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None Nada Yoktur Keiner nenhum Aucun Nessuno Gralnik & Castellanos Nov 2013

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This training about psychotropic medications was developed for clinicians to help them make informed decisions and monitor consumers who are prescribed these medications. This training reviews expectations for the safe and effective use of psychotropic medications in the State of Florida. Disclaimer The author and SFBHN have used reasonable care and skill in compiling the content of this training. However, we accept no responsibility or liability for any inaccuracy or errors and omissions, or for any damage or injury to persons or property arising out of the accessing or use of any of the materials contained in this presentation and material accessed from it. Individual prescribers are responsible for their prescribing practices. Specific questions about medications should be consulted with the prescriber. 3 Psychotropic Medications Training 2014

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Recognize common mental health disorders in children & adolescents. Identify effective treatment options for these mental health disorders. Identify the names and indications for use of commonly prescribed psychotropic medications. Recognize how psychotropic medications are used. Recognize common psychotropic medication side effects. Identify your responsibilities in the treatment process. Identify what to do if you have concerns about the psychotropic medications prescribed to consumers whose care you are involved with. 4 Psychotropic Medications Training 2014

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Psychotropic medications (sometimes called psychotherapeutic medications) are used to treat emotional and behavioral health symptoms and psychiatric disorders. They affect mood, thoughts, behaviors, and how a person processes information and perceives his or her surroundings. 5 Psychotropic Medications Training 2014

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Psychotropic medication must not be used as a method of discipline or control for any consumer. Psychotropic medications are not to be used instead of or as a substitute for identified therapy or behavioral interventions and supports required to meet a consumers mental health needs. 6 Psychotropic Medications Training 2014

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The FDA observes that accepted medical practice includes medication use that is not reflected in approved medication labeling. This is called off label use. Many psychotropic medications that are not FDA approved for a specific use can be used off label to appropriately manage different and difficult problems. Off label psychotropic medication use may be justified when the benefits of treatment outweigh the risks. Without treatment, these consumers could at times suffer serious or dangerous consequences. 7 Psychotropic Medications Training 2014

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General population: About 20% of children in the general population have some form of a mental health disorder. Approximately 40% of youth have co-occurring disorders. Foster care: The national range of children in foster care that have significant mental health problems is 23-80% In Miami-Dade and Monroe Counties during FY 2011-2012, approximately 82% of children in foster care had a diagnosable Axis I mental health disorder. Even when compared to children in similar social class and demographics, foster children are at greater risk for mental health problems. 8 Psychotropic Medications Training 2014

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General population: About 20% of children in the general population have some form of a behavioral health disorder. Approximately 40% of youth have co-occurring disorders. Foster care: The national range of children in foster care that have significant behavioral health problems is 23-80% Even when compared to children in similar social class and demographics, foster children are at greater risk for behavioral health problems. 9 Psychotropic Medications Training 2014

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The most common disorders in children and adolescents include: Anxiety Disorders Disruptive Behavior Disorders (ADHD, Oppositional Defiant Disorder, Conduct Disorder) Depressive Disorders (Major Depressive Disorder and Persistent Depressive Disorder/ FKA Dysthymic Disorder) Substance Use Disorders (mainly adolescents). Schizophrenia is not commonly found in childhood. 10 Psychotropic Medications Training 2014

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Psychotropic Meds Training 2014 Source: www.nami.org

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Mental health matters at every stage of life and requires an integrated continuum of services ranging from prevention to recovery. Mental health can be improved: With earlier identification and intervention. With improved access to services at the right time. By establishing best practices and improving standards of care. By coordinating mental health care across school, medical and community environments. 12 Psychotropic Medications Training 2014

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The Treatment Plan is a tool that helps coordinate, monitor and guide treatment interventions. The Treatment Plan: Should be developed based on the best available evidence. Involves a continuous process that is updated on a regular basis and as needed. Defines target problems that will be the focus of treatment. Defines the plan to monitor the child, short and long term. 13 Psychotropic Medications Training 2014

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A multitude of interventions may be indicated in helping children in out of home care. Treatment may involve: Therapy Educational interventions Structure Medications REMEMBER: Psychotropic medications should only be used as one part of a comprehensive treatment plan. 14 Psychotropic Medications Training 2014

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Many kinds of psychotherapies exist. There is no "one-size-fits-all" approach. Some therapies have been scientifically tested more than others. The goal is to utilize more Evidenced-Based therapies. Sometimes psychotherapy alone may be the best treatment for a person, depending on the illness and its severity. Sometimes, psychotherapy is combined with medications. The kind of psychotherapy a child receives depends on his or her needs. 15 Psychotropic Medications Training 2014

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The classes of psychotropic medications to be reviewed are: Stimulants and Other Medications Used to Treat ADHD Antidepressants Antipsychotics Mood stabilizers Anxiolytics Miscellaneous: Antihistamine Medications Medications used to Treat Side Effects of Antipsychotics Remember: Not all medications your consumer is taking may be covered here. 17 Psychotropic Medications Training 2014

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18 Psychotropic Medications Training 2014 Stimulants & Other Medications Used to Treat ADHD SFBHN Psychotropic Medications Training

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Stimulants and other medications are commonly used to treat Attention-Deficit/Hyperactivity Disorder (ADHD). Symptoms of ADHD interfere with functioning at school, work and in daily living and may include: Short attention span. Inability to stay still. Being impulsive. 19 Psychotropic Medications Training 2014

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FDA MaxFDA Approved for ADHD Generic NameBrand Nameper dayChildren & AdolAdults Mixed Amphetamine saltsAdderall40 mg Yes No Mixed Amphetamine salts XRAdderall XR30 mg Yes ClonidineCatapres *0.4 mg No MethylphenidateDaytrana Patch30 mg Yes No Methylphenidate ER Concerta Metadate CD Ritalin LA Quillivant XR 72 mg 60 mg Yes DextroamphetamineDexedrine40 mg Yes No DexmethylphenidateFocalin20 mg Yes No Dexmethylphenidate XRFocalin XR30 mg Yes Guanfecine ERIntuniv *4 mg Yes No Clonidine ERKapvay *0.4 mg Yes No MethylphenidateRitalin60 mg Yes No AtomoxetineStrattera *100 mg Yes GuanfecineTenex *4 mg No LisdexamphetamineVyvanse70 mg Yes BupropionWellbutrin SR/XL*300 mgNo 20 SFBHN Psychotropic Medications Training 2014

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Groups: Stimulants: Usually first line/choice meds Controlled substances Amphetamine based Methylphenidate Non-stimulant medications: NOT controlled substances Atomoxetine Clonidine, clonidine ER & guanfecine, guanfecine ER Others (typically off label) 21 Psychotropic Medications Training 2014

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What does it mean that stimulants are controlled substances by DEA (Schedule II)?: One prescription supply only (usually one month) No refills Cannot be called in or faxed to the pharmacy (Paper prescription is needed) Potential for abuse 22 Psychotropic Medications Training 2014

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Examples of stimulants (DEA Schedule II controlled substances): Mixed Amphetamine salts: Adderall , Adderall XR Methylphenidate: Ritalin , Daytrana Patch Methylphenidate ER: Concerta , Metadate CD , Ritalin LA Quillivant XR Dextroamphetamine: Dexedrine Dexmethylphenidate: Focalin , Focalin XR Lisdexamphetamine: Vyvanse 23 Psychotropic Medications Training 2014

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Decreased appetite Stomachaches Headaches Trouble falling asleep Irritability Higher blood pressure and heart rate Jitteriness Being too quiet Tics Problems with growing 24 Psychotropic Medications Training 2014

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Rare, Unexpected, Serious Psychosis/Mania Cardiovascular Risks (May include sudden cardiac death, dizziness, chest pain, stroke and arrhythmias in persons with serious pre-existing heart problems). Skin rashes Dependence 25 Psychotropic Medications Training 2014

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Nonstimulants: Atomoxetine (Strattera ) - Side Effects: Stomach aches Increased liver enzymes Suicidal behaviors Clonidine, clonidine ER/Kapvay & guanfecine, guanfecine ER/Intuniv - Side Effects: Tiredness Sedation Headaches Stomach aches Lowering of blood pressure 26 Psychotropic Medications Training 2014

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Time (hours) 0510 0 15 20 Mean plasma levels (ng/mL) 5 10 Methylphenidate Concerta Adderall XR Vyvanse Effective concentration SFBHN Psychotropic Medication Training 2014

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FDA MaxFDA Approved for ADHD Generic NameBrand Nameper dayChildren & AdolAdults Mixed Amphetamine saltsAdderall40 mg Yes No Mixed Amphetamine salts XRAdderall XR30 mg Yes ClonidineCatapres *0.4 mg No MethylphenidateDaytrana Patch30 mg Yes No Methylphenidate ER Concerta Metadate CD Ritalin LA Quillivant XR 72 mg 60 mg Yes DextroamphetamineDexedrine40 mg Yes No DexmethylphenidateFocalin20 mg Yes No Dexmethylphenidate XRFocalin XR30 mg Yes Guanfecine ERIntuniv *4 mg Yes No Clonidine ERKapvay *0.4 mg Yes No MethylphenidateRitalin60 mg Yes No AtomoxetineStrattera *100 mg Yes GuanfecineTenex *4 mg No LisdexamphetamineVyvanse70 mg Yes BupropionWellbutrin SR/XL*300 mgNo 29 SFBHN Psychotropic Medications Training 2014

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30 Psychotropic Medications Training 2014 Antidepressants SFBHN Psychotropic Medications Training

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Antidepressants are used in consumers to treat: Depressive disorders Anxiety disorders Obsessive-Compulsive Disorder (OCD) other conditions. 31 Psychotropic Medications Training 2014

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Child & Adolescent- Only 2 antidepressants are FDA approved for the treatment of major depressive disorder in children and adolescents: fluoxetine (Prozac; 8 17 yo) escitalopram (Lexapro; 12 17 yo) 32 Psychotropic Medications Training 2014

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Generic NameBrand Name FDA Max per day FDA Approved for Major Depression VortioxetineBrintellix 20 mg Adults CitalopramCelexa 60 mg Adults DuloxetineCymbalta 60 mg Adults VelanfaxineEffexor 225 mg Adults Venlafaxine XREffexor XR 225 mg Adults SelegineEmsam patch 12 mg Adults FetzimaLevomilnacipran CR 120 mg Adults EscitalopramLexapro 30 mg Children & Adol (12-17); Adults FluvoxamineLuvox 300 mg No Fluvoxamine CRLuvox CR 300 mg No ParoxetinePaxil, Pexeva 50 mg Adults Paroxetine CRPaxil CR 62.5 mg Adults DesvenlafaxinePristiq 400 mg Adults FluoxetineProzac 60 mg Children & Adol (8-17); Adults MirtazapineRemeron 45 mg Adults FluoxetineSerafem 80 mg No DoxepinSilenor 6 mg No VilazodoneViibryd 40 mg Adults BupropionWellbutrin 450 mg Adults Bupropion SR/XLWellbutrin SR/XL 400 mg(SR) / 450(XL) Adults SertralineZoloft 200 mgs Adults SFBHN Psychotropic Medications Training 2014

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Generic NameBrand Name FDA Max per day FDA Approved for Major Depression ClomipramineAnafranil 200 mg (children/adol) 250 mg (adults) No DoxepinSinequan300 mgAdults TrazodoneDesyrel300 mgAdults AmitryptilineElavil300 mgAdults NortryptilinePamelor200 mgAdults ImipramineTofranil300 mgAdults 34 SFBHN Psychotropic Medications Training 2014

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Anxiety Disorders: Antidepressant medications have an anti-anxiety effect. Some of these medications are considered first line medications (off label) in the treatment of anxiety disorders in children and adolescents. Obsessive Compulsive Disorder (OCD): Certain antidepressants are FDA approved for the treatment of OCD in children and adolescents: clomipramine (Anafranil) fluoxetine (Prozac) fluvoxamine (Luvox) sertraline (Zoloft). 35 Psychotropic Medications Training 2014

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Antidepressant medications can be effective in the treatment of other disorders. In ADULTS Certain antidepressants are FDA approved for the treatment of: Bulimia Nervosa Generalized Anxiety Disorder Obsessive Compulsive Disorder (OCD) Panic Disorder Premenstrual Dysphoric Disorder (PMDD) Posttraumatic Stress Disorder (PTSD) Social Anxiety Disorder (FKA Social Phobia) 36 Psychotropic Medications Training 2014

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Generic NameBrand Name Bulimia Nervosa Generalized Anxiety Disorder Obsessive Compulsive Disorder Panic Disorder Premenstrual Dysphoric Disorder Posttraumatic Stress Disorder Social Anxiety Disorder VortioxetineBrintellix CitalopramCelexa DuloxetineCymbalta VelanfaxineEffexor Venlafaxine XREffexor XR SelegineEmsam patch FetzimaLevomilnacipran CR EscitalopramLexapro FluvoxamineLuvox Fluvoxamine CRLuvox CR ParoxetinePaxil, Pexeva Paroxetine CRPaxil CR DesvenlafaxinePristiq FluoxetineProzac MirtazapineRemeron FluoxetineSerafem DoxepinSilenor VilazodoneViibryd BupropionWellbutrin Bupropion SR/XLWellbutrin SR/XL SertralineZoloft SFBHN Psychotropic Medications Training 2014

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Headache Nausea Upset stomach Trouble sleeping Jitteriness Dry mouth Easily bruising 38 Psychotropic Medications Training 2014

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Rare, Unexpected, Serious Low blood sodium Allergic reactions Seizures (bupropion/Wellbutrin) Mania. 39 Psychotropic Medications Training 2014

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Child, Adolescents & Young Adults- A boxed warning is used by the FDA to alert doctors and patients that special care should be exercised when using antidepressants: Antidepressants increased the risk compared to placebo of suicidal thinking and behavior (suicidality) in children, adolescents, and young adults in short-term studies of major depressive disorder (MDD) and other psychiatric disorders. REMEMBER: Children, adolescents & young adults (< 24 yo) taking an antidepressant should be monitored for new or worsened suicidal thoughts and behaviors. Talk to the doctor or the prescriber if this happens. 40 Psychotropic Medications Training 2014

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SSRIs FDA Category C pregnancy precaution: no adequate and well-controlled studies in humans to determine the effect of the SSRI on the fetus. Research findings on the effects of antidepressants on the growing baby are mixed and inconclusive. Even though most risks found by researchers have been low, the potential risk of a rare heart and lung condition known as persistent pulmonary hypertension of the newborn (PPHN) has been identified. Antidepressants should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus. Psychotropic Medication Training 2014

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Generic NameBrand Name FDA Max per day FDA Approved for Major Depression VortioxetineBrintellix 20 mg Adults CitalopramCelexa 60 mg Adults DuloxetineCymbalta 60 mg Adults VelanfaxineEffexor 225 mg Adults Venlafaxine XREffexor XR 225 mg Adults SelegineEmsam patch 12 mg Adults FetzimaLevomilnacipran CR 120 mg Adults EscitalopramLexapro 30 mg Children & Adol (12-17); Adults FluvoxamineLuvox 300 mg No Fluvoxamine CRLuvox CR 300 mg No ParoxetinePaxil, Pexeva 50 mg Adults Paroxetine CRPaxil CR 62.5 mg Adults DesvenlafaxinePristiq 400 mg Adults FluoxetineProzac 60 mg Children & Adol (8-17); Adults MirtazapineRemeron 45 mg Adults FluoxetineSerafem 80 mg No DoxepinSilenor 6 mg No VilazodoneViibryd 40 mg Adults BupropionWellbutrin 450 mg Adults Bupropion SR/XLWellbutrin SR/XL 400 mg(SR) / 450(XL) Adults SertralineZoloft 200 mgs Adults SFBHN Psychotropic Medications Training 2014

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Generic NameBrand Name FDA Max per day FDA Approved for Major Depression ClomipramineAnafranil 200 mg (children/adol) 250 mg (adults) No DoxepinSinequan300 mgAdults TrazodoneDesyrel300 mgAdults AmitryptilineElavil300 mgAdults NortryptilinePamelor200 mgAdults ImipramineTofranil300 mgAdults 44 SFBHN Psychotropic Medications Training 2014

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45 Psychotropic Medications Training 2014 Antipsychotics SFBHN Psychotropic Medications Training

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These medications may improve: Psychotic symptoms (eg, hallucinations, delusions, impaired reality, disorganized thinking, etc). Bipolar mood changes, such as manic episodes; bipolar depression less so. Depression, as an adjunct to antidepressants. Irritability, associated with autism spectrum disorder. Agitation or aggression. 46 Psychotropic Medications Training 2014

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Antipsychotic medications are FDA approved to treat: Schizophrenia spectrum & other psychotic disorders Bipolar and related disorders Major Depressive Disorder (augmentation) Autism Spectrum Disorder (irritability): Aripiprazole (Abilify) Risperidone (Risperdal) Acute treatment of agitation: Aripiprazole (Abilify) Loxitane (Adasuve#) - Inhaler Olanzapine (Zyprexa) Ziprasidone (Geodon) 47 Psychotropic Medications Training 2014

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The following antipsychotic medications are FDA approved for the treatment of schizophrenia in adolescents 13-17 years: aripiprazole (Abilify) haloperidal (Haldol; 3-17 yo) olanzapine (Zyprexa) quetiapine (Seroquel) risperidone (Risperdal). 48 Psychotropic Medications Training 2014

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The following antipsychotic medications are FDA approved for the treatment of acute manic or mixed episodes associated with Bipolar I Disorder in youngsters 10-17 years: aripirprazole (Abilify) olanzapine (Zyprexa; 13-17 years only) quetiapine (Seroquel) risperidone (Risperdal). 49 Psychotropic Medications Training 2014

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The following antipsychotic medications are FDA approved for the treatment of the symptomatic treatment of irritability associated with children and adolescents with autistic disorder: aripiprazole (Abilify) risperidone (Risperdal) 50 Psychotropic Medications Training 2014

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Generic NameBrand Name Schizophrenia (13-17 yo) Bipolar I Disorder (10-17 yo) Autism Spectrum Disorder (6-17 y0) AripiprazoleAbilify OlanzapineZyprexa (13-17) QuetiapineSeroquel RisperidoneRisperdal HaloperidalHaldol (03-17) SFBHN Psychotropic Medications Training 2014

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Generic NameBrandFDA Rec MaxFDA Approved for Nameper daySchizophreniaMania/Bipolar Aripiprazole Abilify # 30 mg Adol (13-17) Adults Child & Adol (10-17); Adults LoxapineAdasuve10 mg (Inhaled)Adults- Agitation ClozapineClozaril900 mgAdultsNo IloperidoneFanapt24 mgAdults ZiprasidoneGeodon80 mgAdults PaliperidoneInvega12 mgAdults LatudaLurasidone 160 mg- Schizophrenia 120 mg-BPD Depression Adults Adults (Bipolar Depression only) Risperidone Risperdal # 8 mg Adol (13-17) Adults Child & Adol (10-17); Adults Risperidone Risperdal Consta * 50 mg/2 wksAdults AsenapineSaphris20 mgAdults QuetiapineSeroquel800 mg Adol (13-17); Adults Child & Adol (10-17); Adults OlanzapineZyprexa20 mg Adol (13-17); Adults Adol (13-17); Adults 52 SFBHN Psychotropic Medications Training 2014 # Also approved for use in children with Autistic Spectrum Disorder * Long acting injection

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Generic NameBrand NameFDA Max per day FDA Approved for SchizophreniaMania/Bipolar Haloperidal Haldol 60 mg Child & Adol (3-17) Adults No HaloperidalHaldol Decanoate*300 mg/moAdultsNo LoxapineLoxitane250 mg Child & Adol (12-17) Adults No ThioridazineMellaril800 mgAdultsNo ThiothixeneNavane60 mg Child & Adol (12-17) Adults No Pimozide Orap 10 mgNo Fluphenazine No current brand name exists 40 mgAdultsNo FluphenazineProlixin Decanoate*75 mg/2 wksAdultsNo TrifluoperazineStelazine80 mg Child & Adol (6-17) Adults No ChlorprmazineThorazine2,000 mg Child & Adol (1-17) Adults No PerphenazineTrilafon64 mgAdultsNo 53 SFBHN Psychotropic Medications Training 2014 Approved for use in Tourette's Disorder * Long acting injection

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54 Psychotropic Medications Training 2014 Bipolar Depression Mania Maintenance Euthymia/Baseline Hypomania

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55 Bipolar Depression Mania Maintenance Euthymia/Baseline Hypomania D MDD Psychotropic Medications Training 2014

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Generic NameBrand Name Major Depressive Disorder (Augmentation) Bipolar Depression Agitation- Acute Treatment AripiprazoleAbilify LoxapineAdasuve ZiprasidoneGeodon LurasidoneLatuda QuetiapineSeroquel Quetiapine + Fluoxetine Symbyax OlanzapineZyprexa SFBHN Psychotropic Medications Training 2014

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Most antipsychotics are associated with decreased appetite and weight loss.

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Drowsiness Dizziness Dry mouth Blurred vision Constipation Stiffness Restlessness Drooling Rapid heartbeat Sensitivity to the sun Skin rashes Increased appetite and weight gain Menstrual problems 59 Psychotropic Medications Training 2014

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Rare, unexpected, serious Enlargement of breasts in males Galactorrhea (flow of milk from the breast when not pregnant) Dangerous drop in white blood cells (clozapine). Seizures (clozapine) Tardive dyskinesia (TD; potentially irreversible involuntary movements) Neuroleptic malignant syndrome (NMS; increased temperature, muscular rigidity, altered mental state, changes in kidney functioning). 60 Psychotropic Medications Training 2014

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QT prolongation (changes in hearts electrical activity): May prolong QT interval and may be associated with arrhythmia and sudden death. Use with caution in children and adolescents with cardiovascular problems. 61 Psychotropic Medications Training 2014

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Metabolic Changes: Atypical antipsychotic drugs have been associated with metabolic changes that may increase cardiovascular/ cerebrovascular risk, such as: heart disease stroke diabetes These metabolic changes include: Increased blood sugar (hyperglycemia) Increased lipids (dyslipidemia) Weight gain 62 Psychotropic Medications Training 2014

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FDA Category C pregnancy precaution Antipsychotics are associated with increased gestational weight & diabetes and with increased risk of preterm birth. Findings in relation to malformations are inconclusive. Potential risk for abnormal muscle movements (extrapyramidal signs or EPS) and withdrawal symptoms in newborns whose mothers were treated with these drugs during the third trimester of pregnancy. Clozapine is considered a Category B medication. Psychotropic Meds Training 2014

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Generic NameBrandFDA Rec MaxFDA Approved for Nameper daySchizophreniaMania/Bipolar Aripiprazole Abilify # 30 mg Adol (13-17) Adults Child & Adol (10-17); Adults LoxapineAdasuve10 mg (Inhaled)Adults- Agitation ClozapineClozaril900 mgAdultsNo IloperidoneFanapt24 mgAdults ZiprasidoneGeodon80 mgAdults PaliperidoneInvega12 mgAdults LatudaLurasidone 160 mg- Schizophrenia 120 mg-BPD Depression Adults Adults (Bipolar Depression only) Risperidone Risperdal # 8 mg Adol (13-17) Adults Child & Adol (10-17); Adults Risperidone Risperdal Consta * 50 mg/2 wksAdults AsenapineSaphris20 mgAdults QuetiapineSeroquel800 mg Adol (13-17); Adults Child & Adol (10-17); Adults OlanzapineZyprexa20 mg Adol (13-17); Adults Adol (13-17); Adults 65 SFBHN Psychotropic Medications Training 2014 # Also approved for use in children with Autistic Spectrum Disorder * Long acting injection

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Generic NameBrand NameFDA Max per day FDA Approved for SchizophreniaMania/Bipolar Haloperidal Haldol 60 mg Child & Adol (3-17) Adults No HaloperidalHaldol Decanoate*300 mg/moAdultsNo LoxapineLoxitane250 mg Child & Adol (12-17) Adults No ThioridazineMellaril800 mgAdultsNo ThiothixeneNavane60 mg Child & Adol (12-17) Adults No Pimozide Orap 10 mgNo Fluphenazine No current brand name exists 40 mgAdultsNo FluphenazineProlixin Decanoate*75 mg/2 wksAdultsNo TrifluoperazineStelazine80 mg Child & Adol (6-17) Adults No ChlorprmazineThorazine2,000 mg Child & Adol (1-17) Adults No PerphenazineTrilafon64 mgAdultsNo 66 SFBHN Psychotropic Medications Training 2014 Approved for use in Tourette's Disorder * Long acting injection

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67 Psychotropic Medications Training 2014 Mood Stabilizers SFBHN Psychotropic Medication Training

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Mood stabilizers are medications used to treat bipolar disorder with or without an antipsychotic. Many antiepileptic medications (medicines for seizures) can work as mood stabilizers. Interventions for bipolar disorder are not necessarily directed at curing the disorder but at optimally managing it over time. The outcome is better when treatment is continuous rather than on and off over time. 68 Psychotropic Medications Training 2014

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Generic NameBrand NameFDA Max per day FDA Approved for Bipolar Disorder Divalproex/Valproic AcidDepakote/Depakene*60 mg / kgAdults LithiumEskalith / Lithobid*1,800 mgAdults LamotrigineLamictal0.15-3.0 mg / kgAdults GabapentinNeurontin1,800 mgNo CarbamazapineTegretol / Equetro* 1,000 mg children; 1,200 mg adults Adults TopiramateTopamax5-9 mg / kgNo OxcarbazapineTrileptal1,800 mgNo 69 Psychotropic Medications Training 2014

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Excessive thirst Frequent urination Nausea Fine hand tremor Muscles twitches Acne Itching, rash EKG changes Weight gain. 70 Psychotropic Medications Training 2014 O

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Rare, unexpected, serious Blackouts Loss of coordination Seizures Slurred speech Fast, slow, irregular, or pounding heartbeat. Hallucinations Changes in vision Swelling of the eyes, face, lips, tongue, throat, hands, feet, ankles, or lower legs. Hypothyroidism. 71 Psychotropic Medications Training 2014

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Changes in weight Nausea Stomach pain Vomiting Anorexia Changes in appetite. Vomiting Diarrhea Constipation Skin rash Increased suicidal thoughts and behaviors. Rare, unexpected, serious Liver or pancreatic damage Polycystic ovarian syndrome (PCOS). 72 Psychotropic Medications Training 2014

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Headaches Dizziness Diarrhea Rash Pruritus (itchiness) Negative mood adverse reactions Sleep changes Increased suicidal thoughts and behaviors. Rare, unexpected, serious Liver or pancreatic damage Steven Johnson Syndrome: A serious, potentially fatal allergic reaction that leads to a skin rash and sores in the mouth. REMEMBER: If a consumer develops a rash while taking Lamotrigine (Lamictal) immediately contact the doctor. 73 Psychotropic Medications Training 2014

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Mood stabilizers may effect the metabolism, liver, kidneys, and thyroid. Consumers taking Valproic acid / divalproex sodium (Depakote), Lithium or Carbamazepine (Tegretol/Equetro) should have routine blood work to make sure the dose is safe and effective. Levels are usually checked in the morning before the medication is given to the consumer. 74 Psychotropic Medications Training 2014

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The FDA has issued a warning for all of the mood stabilizers listed previously EXCEPT lithium. This warning alerts people to the increased risk of suicidal thinking and behavior REMEMBER: Consumers taking any mood stabilizer (except lithium) should be monitored for new or worsened suicidal thoughts and behaviors. Talk to the doctor or prescriber if this happens. 75 Psychotropic Medications Training 2014

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Caution should be exercised when Consumers with pre-existing medical problems are prescribed a mood stabilizer in which there may be an interaction. Examples: lithium in persons with renal, cardiovascular or thyroid problems divalproex (Depakote) in persons with liver problems topiramate (Topamax) in consumers with glaucoma. 76 Psychotropic Medications Training 2014

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Category C: No adequate and well-controlled studies in humans to determine the effect of the SSRI on the fetus. Lamotrigine (Lamictal) Gabapentin (Neurontin) Oxcarbazepine (Trileptal) Category D: There is positive evidence of human fetal risk based on adverse reaction data from investigational or marketing experience or studies in humans, but potential benefits may warrant use of the drug in pregnant women despite potential risks. Lithium (Eskalith, Lithobid) Valproate/divalproex (Depakote) Topiramate (Topamax) Carbamazepine (Tegretol) Psychotropic Meds Training 2014

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Generic NameBrand NameFDA Max per day FDA Approved for Bipolar Disorder Divalproex/Valproic AcidDepakote/Depakene*60 mg / kgAdults LithiumEskalith / Lithobid*1,800 mgAdults LamotrigineLamictal0.15-3.0 mg / kgAdults GabapentinNeurontin1,800 mgNo CarbamazapineTegretol / Equetro* 1,000 mg children; 1,200 mg adults Adults TopiramateTopamax5-9 mg / kgNo OxcarbazapineTrileptal1,800 mgNo 78 SFBHN Psychotropic Medications Training 2014

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79 Psychotropic Medications Training 2014 Anxiolytics & Other Anti-Anxiety Medications SFBHN Psychotropic Medications Training

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Generic NameBrand NameFDA Max per day FDA Approved for Anxiety LorazepamAtivan10 mgAdults BuspironeBuspar *60 mgAdults ClonazepamKlonopin4 mgAdults ChlordiazepoxideLibrium 300 mg (IV/IM) Adults DiazepamValium40 mgAdults AlprazolamXanax6 mgAdults 80 SFBHN Psychotropic Medications Training 2014

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Anxiolytics or anti-anxiety medications and antidepressants are the most commonly used medications for anxiety disorders. Benzodiazepines (BZs) are a group of anxiolytic medications that work differently than antidepressant medications: BZs generally start working more quickly. BZs help improve situational anxiety but are less effective in preventing or maintaining anxiety under control. The effects of BZs usually do not last for a full day. BZs are classified as controlled substances (Schedule IV). BZs can result in dependence. 81 Psychotropic Medications Training 2014

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What does it mean that benzodiazepines are controlled substances by DEA (Schedule IV)?: Can be written with refills if appropriate Can be called in or faxed to the pharmacy Potential for abuse. 82 Psychotropic Medications Training 2014

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Examples of Benzodiazepines (DEA Schedule IV controlled substances): Lorazepam: Ativan Clonazepam:Klonopin Chlordiazepoxide: Librium Diazepam:Valium Alprazolam:Xanax 83 Psychotropic Medications Training 2014

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Buspirone (Buspar) is an anti-anxiety medication that is not a benzodiazepine and: Unlike benzodiazepines typically takes at least two weeks to begin working. Usually should be taken 2 3 times per day. Is not classified as a controlled substance. Has little scientific support for its use in children and adolescents. 84 Psychotropic Medications Training 2014

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Tiredness Drowsiness Dizziness Unsteadiness when walking Upset stomach Blurred vision Headache Confusion Memory problems Nightmares Depression Increased suicidal thoughts and behaviors (clonazepam/Klonopin, clorazepate/Tranxene). 85 Psychotropic Medications Training 2014

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Rare, unexpected, serious Respiratory depression (Dose dependent, with more severe effects occurring with high doses). Disinhibition Hypomania in persons with depression Blood dyscracias (abnormality of blood cells) Liver problems Seizures (withdrawal). 86 Psychotropic Medications Training 2014

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Generic NameBrand NameFDA Max per day FDA Approved for Anxiety LorazepamAtivan10 mgAdults BuspironeBuspar *60 mgAdults ClonazepamKlonopin4 mgAdults ChlordiazepoxideLibrium 300 mg (IV/IM) Adults DiazepamValium40 mgAdults AlprazolamXanax6 mgAdults 87 SFBHN Psychotropic Medications Training 2014

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88 Psychotropic Medications Training 2014 Misc Meds SFBHN Psychotropic Medications Training

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Antihistamine medications, or antihistaminics, primary indication is to treat allergies. These medicines are also contained in certain cold remedies. Partly because of their relatively safe side effect profile, sometimes these medications are used off-label for the management of agitation and aggression. 89 Psychotropic Medications Training 2014

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Drowsiness Excitability (Especially in young children) Dry mouth Increased appetite Itchiness Headaches Diarrhea Constipation Weight gain. Rare, unexpected, serious Shakiness (Usually with higher doses) Seizures (Usually with higher doses) Dangerous drop in white blood cells. 90 Psychotropic Medications Training 2014

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Generic NameBrand NameFDA Max per day FDA Approved for Agitation & Insomnia DiphenhydramineBenadryl100 mgNo HydroxyzineVistaril400 mgNo 91 SFBHN Psychotropic Medications Training 2014

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These medicines can be useful to treat certain side effects secondary to antipsychotic use. Side effects that could be helped with these meds: Muscle stiffness/rigidity Muscle spasms of the back, neck and eyes Drooling 92 Psychotropic Medications Training 2014

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Drowsiness Excitability Dry mouth Blurry vision Nausea/ upset stomach Constipation Weight gain. Rare, unexpected, serious Confusion Inability to urinate 93 Psychotropic Medications Training 2014

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Generic Name Brand Name FDA Max per day FDA Approved to help side effects of Antipsychotics TrihexyphenidylArtane15 mgAdults BenztropineCogentin6 mgAdults SFBHN Psychotropic Meds Training 2014

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What is true informed consent: A joint decision-making process in which the individual, to the extent of his/her capacity, is involved in discussions about his/her health care to improve long-term outcomes and to foster trust and a better clincian- consumer relationship. Engaging individuals helps: Empower them Encourages their active involvement in the decisions that affect their lives Improves adherence Is more likely to have improved health outcomes. 96 Psychotropic Medications Training 2014

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Continuous process: With the individual Family, caretakers or other important people involved are the mediators. Information must be presented at age, intellectually and developmentally appropriate level and language There is no substitute for informed individuals. 97 Psychotropic Medications Training 2014

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What is the name of the medicine? Is it also called by other names? What do we know about how it helps other individuals who have a similar condition? How will the medicine help me? How long before I see if I get better? When will it work? What are the side effects or reactions which commonly can happen with this medication? Can I get addicted to this medicine? Can it be abused? What is the recommended dosage or amount to take? How many times a day do I take the medicine? Are there any blood or other tests (e.g. heart tests, blood test, etc.) which need to be done before I begin taking the medicine? Will any tests need to be done while I take the medicine? 98 Psychotropic Medications Training 2014

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Will a psychiatrist or other prescriber be checking to see how I am doing with my medicine and make changes if needed? How often will I go for appointments and who will do it? Are there interactions or bad reactions between this medicine and other medicines (prescription and/or over-the-counter) I am taking? Are there any activities that I should avoid while taking the medicine? Should I take any special care for other activities? How long will I need to take this medicine? How will the decision be made to stop this medicine? What do I do if a problem comes up (e.g. if I become sick, doses are missed, or if I get side effects or bad reactions)? 99 Psychotropic Medications Training 2014

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100 Psychotropic Medications Training 2014 Monitoring for Possible Side Effects or To See if the Psychotropic Medication is Helping

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Monitoring for possible side effects or see if the psychotropic medication is helping: Use common sense! It may sound basic Always know if a child is being prescribed medications. Understand what the specific medication is supposed to help with. You need to know what the medicine is supposed to be doing to be able to monitor if it is helping. 101 Psychotropic Medications Training 2014

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Obtain regular feedback from the caregiver or any other person involved in the childs life, such as the childs teacher and/or other school personnel. Examples include: Has the child shown any changes? Is the child even taking the medication? Ask the child how they are feeling both physically and emotionally. Remember if not sure - Discuss with a supervisor. 102 Psychotropic Medications Training 2014

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Use common sense! Report concerns or questions of possible side effects to the childs physician. This may require some persistence. Insist on a call back. Make yourself available for a call back. Schedule a new appointment if needed. 104 Psychotropic Medications Training 2014

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As with all medical issues, if an emergency is suspected call 911 or arrange for the child to go to the nearest emergency department. If you are not sure what to do = ACT! Discuss with a supervisor. Call the doctor. 105 Psychotropic Medications Training 2014

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Clinicians should be aware: Was an evaluation completed before initiating medication treatment? Has the prescriber provided feedback about the diagnosis and educated the individual (and possibly family and others) regarding the individuals disorder and the treatment and monitoring plan? Has the individual provided consent before initiating medication treatment and at important points during treatment? 106 Psychotropic Medications Training 2014

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Has the individual been engaged in the process? Has the child provided assent (if appropriate)? Has the assent and consent discussion focused on the risk and benefits of the proposed and alternative treatments? Have I reported concerns or questions of possible side effects to the individuals physician? 107 Psychotropic Medications Training 2014

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Assisting Consumers who are being prescribed psychotropic meds: Use common sense! It may sound basic Always know if a consumer is being prescribed medications. Understand what the specific medication is supposed to help with. You need to know what the medicine is supposed to be doing to be able to monitor if it is helping. 108 Psychotropic Medications Training 2014

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Obtain regular feedback from the consumer and any other person involved in the consumers life (as appropriate). Examples include: Has the consumer shown any changes? Is the consumer even taking the medication? Ask the consumer how they are feeling both physically and emotionally. Remember if not sure Consult with the prescriber; discuss with a supervisor. 109 Psychotropic Medications Training 2014

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Use common sense! Can it wait??? Encourage the consumer to contact the prescriber with concerns or questions: This may require some persistence. Insist on a call back. Make themselves available for a call back. Schedule a new appointment if needed. Consider reporting directly to the prescriber concerns or questions of possible side effects. 110 Psychotropic Medications Training 2014

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As with all medical issues, if an emergency is suspected call 911 or arrange for the consumer to go to the nearest emergency department. If you are not sure what to do = ACT! Discuss with a supervisor. Call the doctor. 111 Psychotropic Medications Training 2014

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Medications can be an important part of treatment for some emotional and behavioral disorders. Psychotropic medications should only be used as one part of a comprehensive treatment plan. Ongoing evaluation and monitoring by a physician is essential. Each clinician is also an important part of the monitoring process. Informed decision making is important. 112 Psychotropic Medications Training 2014

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APPROPRIATE use of medications is the key. Taking too much or too little of a medication can have undesired consequences! It is very important to take medications as prescribed. Consumers should never add or stop a medication without consulting the prescribing doctor. 113 Psychotropic Medications Training 2014

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