# Presentation: 167356

## 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

## Latest Medications

- 1. Antidepressant/Antianxiety Agents (older = fluoxetine, sertraline, paroxetine, fluvoxamine, buproprion)
- escitalopram (Lexapro), 10-30 mg daily
- citalopram (Celexa), 20-80 mg daily
- venlafaxine (Effexor XR), 37.5-300 mg daily

## Latest Medications (continued)

- 2. Mood Stabilizing Agents (usual = lithium, valproate, carbamazepine)
- lamotrigine (Lamictal), 100-500 mg daily (bipolar depression)
- oxcarbazepine (Trileptal), 600-2400 mg daily (no blood levels needed)
- topiramate (Topamax), 50-400 mg daily (weight loss side-effect, often second agent)

## Latest Medications (continued)

- 3. Antipsychotic Agents (usual = risperidone, olanzapine, quetiapine, clozapine)
- ziprasidone (Geodon), 80-200 mg daily (with food, weight loss side-effect)
- aripiprazole (Abilify), 10-30 mg daily (weight neutral, partial dopamine agonist)
- risperidone long-acting injection (Risperdal Consta), 25-75 mg every 2 weeks (microspheres in diluent, 3 week lag-time to work)

## Latest Medications (continued)

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

## Latest Medications (continued)

- 5. ADHD Medications (usual = methylphenidate, dextroamphetamine, desipramine)
- amphetamine mixed salts extended-release (Adderall XR), 5-30 mg once daily (half-life 10-13 hours, abuse can cause psychosis)
- methylphenidate extended-release (Ritalin LA), 10-80 mg once daily (half-life 3-4 hours, unclear if more reliable than SR form)

## Latest Medications (continued)

- 5. ADHD Medications (continued)
- atomoxetine (Strattera), 40-100 mg daily (selective norepinephrine reuptake inhibitor, similar action of older TCAs, fewer side-effects)
- modafinil (Provigil), 100-600 mg daily (for narcolepsy, does NOT seem helpful for ADHD in first open label studies)

## 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?

## 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

## 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

## 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

## 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

## 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

## 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

## 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

## 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

## 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

## 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)

## 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

## 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

## 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

## 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

## Common Medications Used

- 1. DEPRESSION
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- paroxetine (Paxil)
- Atypical Antidepressants
- buproprion (Wellbutrin SR)
- venlafaxine (Effexor XR)
- Tricyclic Antidepressants (TCAs--older drugs)
- desipramine (Norpramin)
- nortriptyline (Pamelor)
- amitriptyline (Elavil)

## Common Medications Used (continued)

- 2. ANXIETY
- Selective Serotonin Reuptake Inhibitors (SSRIs)
- citalopram (Celexa)
- escitalopram (Lexapro)
- fluoxetine (Prozac)
- fluvoxamine (Luvox)
- paroxetine (Paxil)
- Atypical Antidepressants
- venlafaxine (Effexor XR)

## Common Medications Used (continued)

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

## Common Medications Used (continued)

- 3. Bipolar Disorders (manic depression)
- Mood Stabilizers
- lithium carbonate (Eskalith)
- divalproate (Depakote)
- carbamazepine (Tegretol)
- Atypical Antipsychotic Agents
- olanzapine (Zyprexa)
- risperidone (Risperdal)
- ziprasidone (Geodon)
- Typical Antipsychotic Agents
- haloperidol (Haldol)

## Common Medications Used (continued)

- 4. Bipolar Depression (Bipolar Type II-usually treated with mood stabilizer and antidepressant)
- Mood Stabilizers
- lamotrigine (Lamictal)
- lithium carbonate (Eskalith)
- divalproate (Depakote)
- carbamazepine (Tegretol)
- Atypical Antipsychotic Agents
- olanzapine (Zyprexa)
- risperidone (Risperdal)

## Common Medications Used (continued)

- 5.  Psychotic Disorder (including Schizophrenia, Schizoaffective Disorder, and Paranoid Psychosis)
- Atypical Antipsychotic Agents
- olanzapine (Zyprexa)
- risperidone (Risperdal)
- ziprasidone (Geodon)
- quetiapine (Seroquel)
- aripiprazole (Abilify)
- clozapine (Clozaril)
- Typical Antipsychotic Agents
- haloperidol (Haldol), perphenazine (Trilafon), thioridazine (Mellaril)

## Common Medications Used (continued)

- 6. Impulsive Disorders (treated according to underlying disorder, if any)
- SSRI and Atypical Antidepressants
- citalopram, escitalopram, fluoxetine, paroxetine, sertraline, venlafaxine
- Mood Stabilizers
- lithium carbonate, divalproate, carbamazepine
- Atypical and Typical Antipsychotic Agents
- risperidone, olanzapine, quetiapine
- haloperidol , thioridazine (Mellaril)
- Adrenergic Agents  (higher doses may help)
- propranolol (Inderal LA, Inderal)

## Common Medications Used (continued)

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

## 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

## 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

## 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

## References

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