Newer Psychotropic Medications David P. Kraft, MD, MPH Region I Mental Health Consultant Region 1 Health and Wellness Conference San Juan, Puerto Rico May 13, 2004

2 Latest Medications 1. Antidepressant/Antianxiety Agents (older = fluoxetine, sertraline, paroxetine, fluvoxamine, buproprion) yescitalopram (Lexapro), mg daily ycitalopram (Celexa), mg daily  venlafaxine (Effexor XR), mg daily

3 Latest Medications (continued) 2. Mood Stabilizing Agents (usual = lithium, valproate, carbamazepine) ylamotrigine (Lamictal), mg daily (bipolar depression) yoxcarbazepine (Trileptal), mg daily (no blood levels needed) ytopiramate (Topamax), mg daily (weight loss side-effect, often second agent)

4 Latest Medications (continued) 3. Antipsychotic Agents (usual = risperidone, olanzapine, quetiapine, clozapine) yziprasidone (Geodon), mg daily (with food, weight loss side-effect) yaripiprazole (Abilify), mg daily (weight neutral, partial dopamine agonist) yrisperidone long-acting injection (Risperdal Consta), mg every 2 weeks (microspheres in diluent, 3 week lag-time to work)

5 Latest Medications (continued) 4. Antianxiety and Sedative Agents (usual = lorazepam, clonazepam, zolpidem, buspirone) yalprazolam extended-release (Xanax XR), 1-10 mg daily (once daily dosing, 11 hour half-life, panic disorder indication) yzaleplon (Sonata), 5-20 mg bedtime (short duration, 1 hour half-life, abuse potential unclear)

6 Latest Medications (continued) 5. ADHD Medications (usual = methylphenidate, dextroamphetamine, desipramine) yamphetamine mixed salts extended- release (Adderall XR), 5-30 mg once daily (half-life hours, abuse can cause psychosis) ymethylphenidate extended-release (Ritalin LA), mg once daily (half-life 3-4 hours, unclear if more reliable than SR form)

7 Latest Medications (continued) 5. ADHD Medications (continued) yatomoxetine (Strattera), mg daily (selective norepinephrine reuptake inhibitor, similar action of older TCAs, fewer side-effects) ymodafinil (Provigil), mg daily (for narcolepsy, does NOT seem helpful for ADHD in first open label studies)

8 Psychotropic Medications and Job Corps Students How can we help students on psychotropic medications while in Job Corps and when preparing to Leave Job Corps?

9 Principles of Psychiatric Medications 1. Medications are a TOOL to help students control feelings, thoughts and behavior 2. Medications are best when COMBINED with counseling and behavioral techniques

10 Principles of Psychiatric Medications (continued) 3. Medications take AT LEAST 2 WEEKS to begin to work (except side-effects) 4. Medications need to be taken at least ONCE A DAY 5. Medications take BETWEEN 1 and 2 WEEKS to stop working, in most cases

11 Principles of Psychiatric Medications (continued) 6. Major CHANGES in medication should be AVOIDED during Job Corps stay (minimize lost training time) 7. Newer medications have FEWER SIDE- EFFECTS 8. Newer medications are usually MORE EXPENSIVE

12 Common Problems Helped with Psychiatric Medications 1. DEPRESSION, especially if chronic, not situational 2. ANXIETY states, including panic, phobic, obsessive-compulsive disorders, and general stress not responsive to counseling or behavior techniques

13 Common Problems Helped with Psychiatric Medications (continued) 3. IMPULSIVE tendencies, especially if explosive and can injure student or others 4. FLASHBACKS from earlier traumatic events, especially if disrupting sleep or concentration 5. LEARNING DIFFICULTIES, especially if ADHD is involved

14 Less Common Psychiatric Problems Helped with Medications 1. PARANOID PSYCHOSIS, may be stabilized on antipsychotic medications and supportive therapy 2. OTHER PSYCHOTIC DISORDER, such as Schizophrenia, Schizoaffective Disorder, where antipsychotic medication can help student overcome some of abnormal features of these disorders

15 Less Common Psychiatric Problems Helped with Medications (continued) 3. BIPOLAR DISORDER, usually stabilized on mood stabilizer and/or atypical antipsychotic agents 4. ADJUSTMENT DISORDERS, if last more than a few weeks, may be helped short-term

16 Obtaining Psychotropic Medications for Students 1. Student brings medications from home, and gets from doctor at home 2. Student’s health insurance pays for medications while in Job Corps 3. Student enrolled in Medicaid at center

17 Obtaining Psychotropic Medications for Students (continued) 4. Job Corps Center provides medications through local pharmacy or government supply house (JC Information Notice 02-18) 5. Center physician/psychiatrist applies for patient assist program of specific drug company for each medication

18 Helping Students Comply with Taking Medications 1. Supply each student a list of medications, when taken, and instructions (if any) 2. Ask wellness staff to tailor times of taking medications to minimize interference with learning schedule 3. Teach students ways to remember to take chronic medications (e.g., dispenser, daily reminder, convenient times)

19 Helping Students Comply with Taking Medications (continued) 4. Help students take medications on own (e.g. over weekends or 2-3 days supply at a time, if safe for them to have medications at dorm) 5. For addictive and abusable substances (sedatives, hypnotics, stimulants), provide no more than a one day supply at a time, to minimize risk of other students getting into medications

20 Helping Students Comply with Taking Medications (continued) 6. Train residential staff in safe use of medications, in order to help students comply with medication regimens 7. Provide training to education and vocation staff, as well as support personnel, concerning the basic principles of using psychotropic medications safely and effectively

21 Preparing Students for Life Beyond Job Corps 1. Update lists of medications, doses, side-effects, and reason for use 2. Help students practice asking their doctors and nurses questions about the medications, and options for care 3. Teach students how to keep track of compliance and recognize changes in their symptoms

22 Preparing Students for Life Beyond Job Corps (continued) 4. Help student develop plans to transfer care and obtain services upon leaving Job Corps, if possible, schedule appointments with doctors, therapists, etc. before leaving 5. Give student written summary of current health and wellness concerns, treatments, present needs, future goals and plans

23 Common Medications Used 1. DEPRESSION xSelective Serotonin Reuptake Inhibitors (SSRIs) citalopram (Celexa) escitalopram (Lexapro) fluoxetine (Prozac) paroxetine (Paxil) xAtypical Antidepressants buproprion (Wellbutrin SR) venlafaxine (Effexor XR) xTricyclic Antidepressants (TCAs--older drugs) desipramine (Norpramin) nortriptyline (Pamelor) amitriptyline (Elavil)

24 Common Medications Used (continued) 2. ANXIETY xSelective Serotonin Reuptake Inhibitors (SSRIs) citalopram (Celexa) escitalopram (Lexapro) fluoxetine (Prozac) fluvoxamine (Luvox) paroxetine (Paxil) xAtypical Antidepressants venlafaxine (Effexor XR)

25 Common Medications Used (continued) 2. ANXIETY (continued) xTricyclic Antidepressants (TCAs--older drugs) desipramine (Norpramin) nortriptyline (Pamelor) amitriptyline (Elavil) xBenzodiazepines (minor tranquilizers)-- [ADDICTIVE, not use with substance abusers] clonazepam (Klonopin) lorazepam (Ativan) diazepam (Valium) alprazolam (Xanax)

26 Common Medications Used (continued) 3. Bipolar Disorders (manic depression) xMood Stabilizers lithium carbonate (Eskalith) divalproate (Depakote) carbamazepine (Tegretol) xAtypical Antipsychotic Agents olanzapine (Zyprexa) risperidone (Risperdal) ziprasidone (Geodon) xTypical Antipsychotic Agents haloperidol (Haldol)

27 Common Medications Used (continued) 4. Bipolar Depression (Bipolar Type II- usually treated with mood stabilizer and antidepressant) xMood Stabilizers lamotrigine (Lamictal) lithium carbonate (Eskalith) divalproate (Depakote) carbamazepine (Tegretol) xAtypical Antipsychotic Agents olanzapine (Zyprexa) risperidone (Risperdal)

28 Common Medications Used (continued) 5. Psychotic Disorder (including Schizophrenia, Schizoaffective Disorder, and Paranoid Psychosis) xAtypical Antipsychotic Agents olanzapine (Zyprexa) risperidone (Risperdal) ziprasidone (Geodon) quetiapine (Seroquel) aripiprazole (Abilify) clozapine (Clozaril) xTypical Antipsychotic Agents haloperidol (Haldol), perphenazine (Trilafon), thioridazine (Mellaril)

29 Common Medications Used (continued) 6. Impulsive Disorders (treated according to underlying disorder, if any) xSSRI and Atypical Antidepressants citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine xMood Stabilizers lithium carbonate, divalproate, carbamazepine xAtypical and Typical Antipsychotic Agents risperidone, olanzapine, quetiapine haloperidol, thioridazine (Mellaril) xAdrenergic Agents (higher doses may help) propranolol (Inderal LA, Inderal)

30 Common Medications Used (continued) 6. ADHD xSelected Antidepressants (SSRIs, Atypicals, TCAs) buproprion (Wellbutrin SR) venlafaxine (Effexor XR) fluoxetine (Prozac), citalopram (Celexa) desipramine (Norpramin) xSNRI (Selective Norepinephrine Reuptake Inhibitor)--[NEW] atomoxetine (Strattera) xPsychostimulants (easily ABUSED by other students, paradoxical calming effect on ADHD student) amphetamine salts (Adderall) dextroamphetamine (Dexedrine) methylphenidate (Ritalin, Metadate, Concerta) pemoline (Cylert)

31 Summary 1. Encourage students to take medications as prescribed, or consult with wellness center staff if problems 2. Support overall goal of student responsibility for behavior, whether or not taking medication

32 Summary (continued) 3. Discourage students from only using medications “when I remember”--to do any good, most need to be taken at least once a day 4. If asked about whether a student should take his/her medication, share your observations of how the medicine may be helping

33 Summary (continued) 5. Look for ways to make medication compliance easier for students 6. Help wellness center staff with ideas about helping students plan for their future

34 References 1. Mosby’s Drug Consult 2004, Mosby, Inc., St. Louis, MO, Physicians’ Desk Reference 2003, Edition 58, Medical Economics Co., Inc., Montvale, NJ, Psychotropic Drugs Fast Facts, by Maxmen JS, Ward NG, WW Norton & Co., New York, 2002.