Download - Medication & Adolescents: Empowerment Through Education Angela Campbell, Pharm.D., MS, BCPP Tawny Smith, Pharm.D., BCPP

Medication & Adolescents: Empowerment Through

Education

Angela Campbell, Pharm.D., MS, BCPP

Tawny Smith, Pharm.D., BCPP

Outline

• List common psychiatric conditions medications may help with in children and adolescents

• Discuss specific psychotropic medication side effects or warnings

• Discuss FDA approval for medications in children and adolescents

• Understand medication-taking behaviors in adolescents

• List tips for providing medication education to adolescents

Using Psychiatric Medications in

Children & Adolescents

Medication Treatment of Psychiatric Disorders in Children and Adolescents• What psychiatric conditions may be treated with

medications?– Depression– ADHD– Anxiety disorders– Bipolar Disorder– Psychosis (Schizophrenia, Schizoaffective disorder, bipolar disorder

with psychotic features, major depression with psychosis)– PTSD– OCD– Irritability associated with autism– Aggression when related to a psychiatric disorder

Symptoms & Diagnosis

• In mental health, many diagnoses can have the same symptoms– Irritability: depression, bipolar disorder, substance

abuse, autism– Aggression: bipolar disorder, ADHD, conduct

disorder, disruptive behavior disorder, schizophrenia

– Depression: major depression, bipolar disorder, schizophrenia

What is the relationship between diagnosis and medications?

• There majority of psychotropic medications are used to treat more than one diagnosis– Antidepressants: depression, anxiety, OCD,

PTSD, eating disorders– Antipsychotic medications: bipolar disorder,

schizophrenia, schizoaffective disorder, irritability associated with autism, major depression (to augment antidepressant effects)

Possible Side Effects of

Psychiatric Medications

Stimulants

• Examples:– Amphetamine salts

• Adderall®/Adderall XR®

– Methylphenidate• Ritalin®/Concerta®/Daytrana®

– Dexmethylphenidate• Focalin®/Focalin XR®

Stimulants: Potential Side Effects• Most common side effect is decreased appetite• Small increases in heart rate and blood

pressure may occur, but are not usually clinically significant

• No increased risk of serious cardiac events– Use caution in people with existing heart problems

• Structural abnormalities (i.e., coronary artery abnormalities, subaortic stenosis)

• Chest pain, irregular heart beat, high blood pressure, or unexplained lightheadedness/fainting

Antidepressants

• Examples:– Fluoxetine/Prozac®

– Sertraline/Zoloft®

– Paroxetine/Paxil®/PaxilCR®

– Citalopram/Celexa®

– Escitalopram/Lexapro®

– Fluvoxamine/Luvox®

– Venlafaxine/Effexor®/ EffexorXR®

– Duloxetine/Cymbalta®

– Bupropion/Wellbutrin®/ WellbutrinSR®/ WellbutrinXL®

– Amitriptyline/Elavil®

– Nortriptyline/Pamelor®/ Aventyl®

– Clomipramine/Anafranil®

– Doxepin/Sinequan®

– Imipramine/Tofranil®Medications in this column typically used infrequently in children and adolescents

Antidepressants: Potential Side Effects• Commonly causes an increase in anxiety for the first

7-10 days of treatment – After this time, begins to help with anxiety

• Monitor closely for new-onset or worsening suicidal thoughts or actions (FDA black box warning)– Particularly during first two weeks of antidepressant

treatment– Increased irritability, aggression, worsening depression,

anxiety, decreased need for sleep, or impulsivity could indicate a switch to mania or worsening suicidality

Antidepressants

• The majority of studies have found that antidepressants have a protective effect against suicide

• Benefits of antidepressants appear to be greater than the risk of suicidal ideation/suicide

Antidepressants

• How should the FDA warning be interpreted?– Increased risk of suicidality possible during first few weeks of

treatment with antidepressants– Assessment, careful and accurate diagnosis, and monitoring

are of the utmost importance– Nonmedication treatment alternatives should be tried first, if

possible– Antidepressants should be used in children and adolescents

who require medication treatment for depression– Initial assessment of suicidality is critical, as is ongoing

monitoring for suicidal thoughts/plans– Know what symptoms to watch for and be aware of

Behavior changes that indicate young person needs help• Sudden drop in grades

• Changes in friends or personality

• Constant thoughts and fears about their personal safety or safety of family members

• Does not want to go to school

• New or frequent complaints of headache, stomach aches, and other sicknesses

• Trouble sleeping or nightmares

Behavior changes that indicate young person needs help (continued)• Prolonged feelings of sadness and loneliness

• Doesn’t care about favorite activities or is “too tired to play”

• Feels angry, getting into fights

• Trouble sitting still or concentrating

• Running away

• Noticeable weight loss or gain

• Talks about death/suicide

Antipsychotics

• Examples:– Aripiprazole/Abilify®

– Asenapine/Saphris®

– Clozapine/Clozaril®

– Iloperidone/Fanapt®

– Lurasidone/Latuda®

– Olanzapine/Zyprexa®

– Paliperidone/Invega®

– Quetiapine/Seroquel®

– Risperidone/Risperdal®

– Ziprasidone/Geodon®

– Chlorpromazine/ Thorazine®

– Fluphenazine/Prolixin®

– Haloperidol/Haldol®

– Loxapine/Loxitane®

– Molindone/Moban®

– Perphenazine/Trilafon®

– Trifluoperazine/ Stelazine®

– Thioridazine/Mellaril®

– Thiothixene/Navane®

Antipsychotics: Potential Side Effects• Possibility for increased appetite and weight

gain– Talk with doctor quickly if weight gain occurs;

easier to address early on

• Possibility to cause extrapyramidal side effects (EPS)– Sudden onset of very stiff muscles/spasms– Restlessness, inability to sit still– Rigid joints, pill-rolling tremor, stiff walk

Antipsychotics: Potential Side Effects• Possibility to cause an increase in prolactin

levels– Change in menstrual cycle, absence of menstrual

cycle, breast growth (males or females), lactation (males or females)

– Not a medical emergency, but let your doctor know!

• Doctor may need to adjust dose or switch medications

Lithium

• Possible side effects: stomach upset, diarrhea, ↑ appetite, weight gain, less clear thinking, feeling tired, shakiness, acne

• Laboratory monitoring is very important!– Can affect the thyroid and kidneys– Can monitor drug levels

• Many things can increase lithium levels– Low salt diet, dehydration, NSAIDs (i.e., ibuprofen,

naproxen), some blood pressure medications

Depakote ® (divalproex, valproic acid)• Possible side effects: shakiness, weight gain,

stomach upset/nausea, dizziness, hair loss,

• Laboratory monitoring is important!– Can affect the liver, pancreas– Can cause decreased platelets and increase

ammonia– Can monitor drug levels

Tegretol ® (carbamazepine)

• Possible side effects: feeling tired, stomach upset, thinking not as clearly, dizziness, rash

• Laboratory monitoring is important!– Can cause unsafe blood cell count problems

(rare) – Can cause low blood sodium levels– Can monitor drug levels

• Interacts with many other medications

Lamictal® (lamotrigine)

• Possible side effects: stomach upset, headache, skin rashes, dizziness, feeling tired– If rash develops, call MD right away, and stop

taking lamotrigine– Rash can worsen and become very serious

requiring medical attention, especially if person continues taking lamotrigine

The Food and Drug Administration (FDA) and Psychotropic Medications in Children

& Adolescents

The Food and Drug Administration and Medications in Children and Adolescents• In order for a medication to gain “FDA approval,” the

company who makes a medication must conduct a study to show it is safe and effective

• Many psychotropic medications do not have FDA approval in children and adolescents– Studies may not be conducted in pediatric patients for many reasons

• The FDA does not regulate physician or other healthcare provider prescribing of medications– The FDA states it “does not limit the manner in which a practitioner

may prescribe an approved drug”– Studies and expert clinical opinion often support the “off label” use of

medications

Psychotropic Medication Utilization Parameters in Foster Children and Youth, DFPS 2013

The Food and Drug Administration and Medications in Children and Adolescents

• Many medications are used “off-label” in children and adolescents

• Often, there are many studies to support that a medication is safe and effective, even if there is not FDA approval

• Discuss with your doctor if you have concerns– Ask if there is evidence to support the use of that

medication in children or adolescents (It is okay to ask this question!)

Medication-taking Behaviors in Adolescents

Adolescents and Medications

• “We should not assume that youth have understood their illness, made sense of their medication treatment, or have adhered to the regimen as adults.”

• “Health research has demonstrated that adolescents draw on personal perceptions, beliefs, and meanings in their experience of medical interventions.”– Example: youth with asthma may modify medical advice

about asthma treatment when they believe their knowledge supersedes that of doctor

Floersch et al. Adolescent Experience of Psychotropic Treatment. Trancult Psychiatry 2009; 46: 157-179

Adolescents [and Medications]

• May assert autonomy by resisting standard treatments

• May not adhere to prescribed medications when they do not feel like taking medication

• May choose not to take their medications when they feel “healthy”

• May stop medications that prevent progression of illness or prevent relapse of illness when the medication does not provide the reinforcement of feeling well or immediate relief of physical symptoms

• May stop taking medications because they feel well or no longer feel the medication is needed



• Studies have shown:– Adolescents may discontinue asthma medication when they do

not recognize symptoms of the illness in themselves, such as shortness of breath (van Es et al. 1998)

– Adolescents with chronic asthma may discontinue medications when they feel the medication is ineffective or feel they don’t have the illness (Buston & Wood 1999; van Es et al. 1998)

– Adolescents with diabetes may resist treatment for diabetes or may not adhere to prescribed treatment when they don’t feel like taking medication (Adams et al. 1997; Kyngas & Hentinen 1995)

– HIV positive adolescents may avoid taking antiretroviral medications when they feel healthy (Pugatch et al. 2002)



• Adolescents respond to medication treatment in profoundly different and personal ways that influence adherence and treatment effectiveness

• The theme of expectation and hope seems particularly important in adolescent medication taking behavior

• So, how can you encourage or influence adolescents to take medications?


Providing Medication Education to Adolescents

Medication Education: Empowering Adolescents• What to discuss with adolescents and their

families about their treatment:– De-stigmatize the experience of mental illness– Give education about the origins, time course,

and treatment options for mental illness– Empower the child/family to get the help they

need and to take charge/control of their own health and well-being

Guidelines for Adolescent Depression in Primary Care 2010 http://www.glad-pc.org/

Medication Education: Empowering Adolescents• Psychiatric medications are challenging because there is

often a long delay before the medication effect “kicks in”– Aspirin for a headache → begins to work in about 30

minutes– Fluoxetine/Prozac™ for depression → begins to work in

about 3-6 weeks• This is a long time to wait to feel better!!

• Important to remind and educate teenagers of this, and to provide encouragement/motivation to continue taking the medication until it begins to help with symptoms– Keep the endpoint in mind!

Things adolescents want to know about mental illness:

• How/why mental illness occurs– Typically occurs due to imbalances of brain

chemicals, called neurotransmitters (too much or too little)

– Often, genetics are involved

– Stress or trauma is often implicated

– Sometimes occurs randomly


Things adolescents want to know about medications:• How psychiatric medications work:

– By helping to regulate brain chemicals (neurotransmitters) which send signals to different parts of the brain and body

– May help normalize the levels of these chemicals in the brain which in turn, improves symptoms of mental illness

– Must take the medication CONSISTENTLY (every day) for it to help


Things adolescents want to know about medications:• Specifically how the medication will help

them:– improved mood

– better concentration

– more normal sleep

– more normal appetite

– greater interest in activities

– more energy


Things adolescents want to know about medications:• Will medication change who I am?:

– Medication will not change who you are or make you different from other young people.

– It will help you get back to the way you were before you became ill so that you feel like yourself again.

– Taking medication is not much different than wearing glasses or braces – it’s only a tool to help you get well or feel better.


Things adolescents want to know about medications:• Are psychiatric medications addicting? Will I

become dependent on them?: – Definition of addiction: compulsive need for and use of a habit-

forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly : persistent compulsive use of a substance known by the user to be harmful

– Definition of dependence: the quality or state of being dependent; especially : the quality or state of being influenced or determined by or subject to another

http://www.merriam-webster.com/dictionary

Things adolescents want to know about medications:• Are psychiatric medications addicting? Will I

become dependent on them? (continued): – Most psychiatric medications are not addicting and do not

cause dependence• Antidepressants, antipsychotics, mood stabilizers, stimulants for ADHD

– Some psychiatric medications have the possibility to be addicting. Generally these are only prescribed for short periods of time to limit the potential for addiction or dependence.

• Benzodiazepines (lorazepam, clonazepam, alprazolam, etc.)• Some sleep medications (zolpidem/Ambien®, eszopiclone/Lunesta®,

etc.)

Things adolescents want to know about medications:

• Are psychiatric medications addicting? Will I become dependent on them? (continued): – Psychotropic medications get a “bad rap” for being

addictive because they do have to be TAKEN to work or cause an effect (just like any medication). If they are not taken, relapse can occur.

– Medications control symptoms and keep illness stable, but must be taken every day, usually long-term

– Currently there is no “cure” for mental illness– Similar to having diabetes, asthma, or thyroid illness –

need daily medication to manage/control mental illness

Things adolescents want to know about medications:• How long will I have to take the medication?:

– If the medication is helpful and you have no problems with it, you will probably need to take the medications for a number of months, even after you feel better to make sure the symptoms are better.

– In some cases (depending on which illness), medications may need to be taken for life.


Things adolescents want to know about medications:• Are psychiatric medications safe to take long-

term/for life?– YES!– Most medications have long studies (several

years in duration) conducted to ensure safety with long-term use

– There have been medication treatments for mental illness since the late 1950’s/early 1960’s


Things adolescents want to know about medications:• Are psychiatric medications safe to take long-

term/for life? (continued)– Usually side effects (unwanted effects) of meds occur

early on in treatment, so possible to adjust or switch medications in order to find the right “one”


Medication Education: Empowering Adolescents• What is my role in taking medications for mental illness?:

– Learn what medication you take, how much to take, and what it is for

– It is your responsibility to take medication in the right amount at the right time (may need help from parents/caregiver!)

– Don’t take other medications without asking your doctor first, even over-the-counter medications

– Never use alcohol or drugs while taking medication. It can be dangerous or deadly.

– Talk with your doctor about any problems you experience while taking medications.

– Even if you feel okay or good, take your medication every day


Medication Education: Empowering Adolescents• Adolescents need to know whether compliance with

medications is important (It is!) and the potential consequences of noncompliance– Medication may not work– Recurrence of illness or symptoms– Potential for hospitalization– Medication may not work as quickly/help as much after

a relapse occurs– Stress that psychiatric medication has to be taken long-

term (EVERY DAY)

Medication Education: Empowering Adolescents• Encourage the adolescent to self-evaluate and

make notes of positive and negative aspects of taking the medication– Mood diary

• Discuss these with the doctor

• May remind adolescent often (daily if needed) about the link between symptoms, behaviors, and feelings and the rationale for taking medications

Strategies for Providing Medication Education to Adolescents

Medication Education: Teaching Adolescents• Important to make medication information

RELEVANT to adolescents– Keep it real

• Give realistic information about time medication typically takes to work

• Give realistic expectations of response to medications or how well medication will potentially work

• Give accurate but not overwhelming information about side effects

– Give information about common side effects

– Give information about “medical emergency” side effects and what to do if they occur (STRESS THAT THESE ARE RARE!)

Medication Education: Teaching Adolescents• Make YOURSELF relevant (Why should they

listen to you?)– Helps to stay (at least a little) up-to-date with

current events in adolescent pop culture– Make the information interesting– Make sure you know what you’re talking about

• Teens respond to knowledgeable and relevant information

• If you sound like (and do!) know what you’re talking about, they typically tune in

Medication Education: Teaching Adolescents• Make the information and delivery of the information

interesting– Energetic delivery

– Use examples

– Use stories

– Use humor

– Work in current events related to your educational topic• Substance abuse example: Lil Wayne recently hospitalized

when he had a seizure after ingesting “sizzurp/purple drank” (i.e., phenergan with codeine cough syrup)

Learning Tools

• Jeopardy-type board games• Educational reading material or websites

– http://www.nami.org/Template.cfm?Section=By_Illness– http://www.glad-pc.org/– http://www.nimh.nih.gov/health/topics/child-and-

adolescent-mental-health/index.shtml– http://www.hhs.gov/ash/oah/adolescent-health-topics/

mental-health/– http://www.psychiatry.org/teens– http://www.who.int/mental_health/prevention/childado/en/

Jeopardy Board Game

Questions?

Download - Medication & Adolescents: Empowerment Through Education Angela Campbell, Pharm.D., MS, BCPP Tawny Smith, Pharm.D., BCPP

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