Download Psychotropic Medication in Foster Youth

Psychotropic Medication
in Foster Youth
Mark Edelstein MD
Medical Director, EMQ FamiliesFirst
[email protected]
June 2015
Agenda
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Agenda Review and Intro
General remarks on meds
Evaluation, diagnosis and treatment planning
Principles of medication use
Special considerations in foster youth
Meds for selected mental health conditions
Working with the doctor
Introduction
• Why this presentation?
– At least 40% of foster kids have a psychiatric disorder
– CPS social workers are part of treatment team
• Psychotropic Medications
– Psychiatric medicines
– Medication intended to affect mood, cognition,
attention or behavior
– Example: Depakote when used to reduce aggressive
outbursts (but not when used to reduce seizures)
Handouts
• Power Point
• Table A: When should meds be part of the
treatment plan?
• Table B: Selected Psychotropic Medications
• Abbreviations
• Information for TARs for antipsychotics
Intro
• What is working in your program?
• What needs improvement?
• What questions should I make sure to
answer today?
Sources of Confusion
• Names of medication classes
• Generic vs. brand names
• “Meds” vs. “Drugs”
– Both are chemicals but meds should solve a problem
and over time help things get better
• Meds control symptoms, not people
Meds in the Body
• Forms: Tablets: only some may be cut
– Tablets, capsules, liquids, chewables, meltalbes
• Meds work mainly (but not only) by modifying
chemical communication between neurons (see next
slide)
• Meds act only while present in the body
• Variation in onset and duration of action
– Absorption, metabolism, excretion
– “In and out” vs. “steady state” meds
Neurons!
Neurotransmitters
• Brain uses multiple NTs: Dopamine, Serotonin,
Norepinephrine, Histamine, Glutamate, GABA, etc.
• Separate pathways/systems for different NTs and
each NT may have variety of receptors
• Though each NT tends to be associated with certain
brain functions (e.g., Dopamine reward system), NT
systems interact
• Examples of how meds work: block re-uptake, block
receptors, stimulate receptors, etc.
FDA Approval
• “FDA approval” means a med can be marketed
• as “safe and effective”
• for one or more specific disorders
• in a specified age group or other population.
• Off-label use in kids is valid and essential
• Companies seldom seek FDA approval for kids
except for ADHD
• Once FDA-approved, a med can be prescribed for
any condition/age
• Ongoing research & clinical experience
Course of Care
• I will describe ideal services
– Most prescriptions are written by PCP’s
– Hx is often unavailable in foster care system
• A partnership
• Evaluation: history, rating scales, interview
– Records made available by CPS can really help
• Diagnosis
– Essential to decisions about medicine
– DSM-IV-TR  DSM-5 (5/13): When will counties switch?
– Codes: switching from ICD-9 to ICD-10 in 10/15
DSM-5 Highlights
• No more Axis I-V
• DSM-5 attempts to:
• Be more clinician-friendly
• Include research findings
• Reduce need for so many NOS diagnoses
• Lists disorders in more sensible order (lifespan)
DSM-5 Highlights
• Lumps some diagnoses together
• Autism Spectrum
• Specific Leaning Disorder
• Language Disorder
• Tries to Simplify and De-Stigmatize
• Intellectual Developmental D/O (not MR)
• Speech Sound D/O (not Phonological D/O)
• Childhood-Onset Fluency Disorder (not Stuttering)
DSM-5 Highlights
• Disruptive Mood Dysregulation Disorder (DMDD)
– Intended to reduce use of Mood Disorder NOS and
Bipolar Disorder NOS
– At least one year of severe recurrent temper outbursts
grossly out of proportion in intensity or duration to the
situation
– Outbursts occur on average at least 3 x per week
– Mood between temper outbursts is generally irritable
or angry
Formulation/Interventions
Psychotropic meds
Other health care
Exercise, diet
Psychoeducation
Individual, Group,
Family Therapy
Skills training with
reinforcement
Emotional Support
Age-appropriate
activities (promote
positive identity,
social/other skills
hope, self-efficacy
BRAIN
MIND
Parents change their behavior
(family therapy, training,
mental health services)
Teachers, sibs, etc. change
behavior
New friends, adult role models
Address family’s social needs
Adapt: change expectations,
physical environment,
schedule
ENVIRONMENT
Formulation/Interventions
• Formulation
– How do we account for the difficulties?
• Presentation of findings to youth and family
• Further assessment if needed
– Labs, rating scales, records, testing, etc.
• Treatment plan
– Typically a combination of interventions
– Evidence-Based Practices are preferred
Meds as part of plan
• Why recommend medication?
– Risk/benefit ratio not of the medicine but of a total
plan that includes medicine vs. one that doesn’t.
• Medicine is not “the last resort”
• Meds are one piece of an overall treatment plan
– Not the sole intervention unless other interventions
have been completed
– If youth/family declines other services, meds may still
make sense.
Why a Certain Med?
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Target symptoms
Age of child
Research
Potential side effects
Family history
Medical conditions
Med interactions and additive side effects
Youth and family preference and convenience
Cooperation with blood draws
Risk of abuse or use of co-occurring drug use
Can child swallow a pill?
What drug rep was there last (!)
Consent & Assent
• Written informed consent
– standard of care in psychiatry
– not in primary care
• Court authorization (JV-220) process
– Will discuss this later
• Assent of youth
Effects of meds
• Target symptoms:
– The effects you want from the med
– Keep these in mind during med trial
• Side effects
– Any effects you don’t want from the med
– Most are mild, not dangerous & respond to a change
in dosing
– There is always the risk of dangerous side effects
– Labs for some meds at baseline & regular intervals
– Unknown effects on developing brain
• Med trial: “Start low & go slow”
Common Side Effects
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sedation or insomnia
fatigue
blood pressure increase or decrease (lightheaded)
headache
upset stomach, constipation or diarrhea
increased or decreased appetite
weight gain or loss
tremor or stiffness
irritability, anxiety, agitation, dysphoria, new
thoughts of suicide (see next slide)
Side Effects
• Rule of thumb: any psychotropic can cause just
about any psychiatric side effect
• Low but real risk of suicidality from antidepressants,
anticonvulsants, Strattera
• Long-term risks include:
– tardive dyskinesia with antipsychotics
– reduced kidney function from Lithium,
– Polycystic ovary disease with Depakote
– Abuse of stimulants or benzodiazepines
– Physical addiction to benzodiazepines
Goals of Active Med
Management
1. Eliminate or at least adequately reduce target
symptoms
2. No side effects - or at least no problematic or
dangerous ones
3. Minimize risk of future side effects (e.g., tardive
dyskinesia, addiction)
4. Lowest effective dose
5. Fewest medications possible (vs. “polypharmacy”)
– watch for “accretion”
6. Shortest duration possible – watch for failure to try
lower doses
Discontinuing Meds
• Taper in order to avoid withdrawal symptoms,
especially anticonvulsants, antidepressants and
adrenergic agonists
• When to discontinue?
• Maximum dose without benefit
• Side effects when dosing change not an option
• New med for same target symptom is effective
• Preferences of youth/family sooner vs. later
• Medical developments – e.g., pregnancy
• Reasonable chance that it can be discontinued
without symptoms returning.
Substance Use
• Little evidence for major interactions with meds
– but research is not extensive & interactions can be
unpredictable, especially with polypharmacy
• One chemical may affect another’s metabolism, e.g.,
– e.g., alcohol induces enzyme that metabolizes Effexor
• May be additive side effects
• Biggest concerns
– Alcohol
– benzodiazepines; lithium (dehydration); stimulants;
tricyclics and MAO inhibitors
Pregnancy
• Risk/benefit ratio
– Depression increases risk of low birth weight; late
term depression & anxiety increase risk of newborn
hypoglycemia and respiratory distress
– Meds may increase risk of malformation
(teratogenesis), neonatal toxicity and withdrawal,
perhaps long term effects (unknown)
• FDA risk categories
– A (research shows no more than remote risk to fetus)
– B, C, D
– X (risk too high to use in pregnancy)
Pregnancy
• Sites
– safefetus.com
– womensmentalhealth.org
• SSRI antidepressants probably safe except Paxil
– But watch for newborn withdrawal.
• Atypical antipsychotics may be relatively safe
• Teratogenesis risk in 1st trimester includes:
– Depakote, Tegretol, Lithium, Benzodiazepines
Other issues for girls
and women
• Breastfeeding
– Concentration of meds in breast milk varies, e.g., low
for antidepressants, high for Lithium
• Oral contraceptives (OC)
– Reduced OC effectiveness by most anticonvulsants
(but not Depakote), Benzodiazepines, Prozac,
Celexa, Zoloft, Provigil
– OC may increase serum level of beta blocker, tricyclic
antidepressants, and diazepam
– OC may decrease level of Tegretol, Lamictal and
temazepam
Foster Youth
• Abuse & Neglect may impact development of both
brain and mind (complex trauma)
• Genetic vulnerability for brain based disorders
• Brain injury - substance exposure, poor prenatal
care, malnutrition, physical injury
• Environment –foster/group home, special education
setting, bio family
• Strengths – influence behavioral expression
• Interactions of these over time
• Co-occurring disorders (“comorbidity”) common
Foster Youth
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Youth & family concerns about addiction
Repeated stressors
Changing reporters (e.g., changes in foster homes)
Foster parents
– May be misinformed about med, dose, purpose
– May be highly opinionated about meds
• Potential meaning to foster youth
– Stigma
– Diagnosis as a label
– Medicine as external control
Foster Youth
• Due to complexity:
– Need comprehensive, collaborative services
– Keep complex etiology in mind during med trials
• Overuse, under-use and misuse result from
– Inadequate training of PCP’s
– Poor access to specialists
– Inadequate psychosocial services
– Pressure from caregivers and others
– “If all you have is a hammer…”
• Potentially great benefit
– Success begets success
Court Authorization
• JV-220(a) completed by prescriber  CPS
• Range of screening
– Some counties (including LA, Alameda, Riverside,
San Bernardino, Contra Costa, San Francisco)
screen all applications (psychiatrist, nurse or
pharmacist)
– Some have consultant available as needed
– Do some “rubber stamp” JV-220?
• Variability in standards used by consultants
Court Authorization
• If there is no objection, may take 1-2 weeks or more
• If there is an objection, hearing is scheduled
• Max authorization 6 months. Then prescriber must
request re-authorization.
• Sometimes Court imposes a condition
• Some courts allow parent to consent if the youth is
living with them
• Watch for meds being started without authorization,
e.g., by PCPs
“Misprescribing”
• Very common
• PCPs prescribe the most psychotropics but have
limited MH training/experience
• Inadequate evaluations
• Wrong med, dose, number, duration
• Inadequate monitoring
• Underuse is high-risk, but an error of omission
• Excessive use is high-risk and gets more attention
because it is an error of commission
Over-Prescribing
• 2011 GAO review of psychotropic youth in 5 states
on Medicaid (2008 data). Common findings:
– Excessive # of meds (e.g., 5)
– Excessive doses (including above maximum)
– Young age (infants!)
– Excessive use of atypical antipsychotics
• Why? Perhaps…
– Inadequate training, bad practice, high volume
– Other services inadequate
– Pressure on prescribers
QIP
• 2011 federal mandate for states to develop protocols
for the appropriate use and monitoring of
psychotropic medication in foster youth.
• Quality Improvement Project
– Calif. Dept. of Healthcare Services
– Calif. Department of Social Services
• Medication Guidelines adopted (next slide)
• Other documents and recommendations pending
QIP Med Documents
• http://www.dhcs.ca.gov/services/Pages/qip-clinical-w.aspx
• California Guidelines for the Use of Psychotropic
Medication with Children and Youth in Foster Care
– 16 pages; covers basics principles of medication use
• App. A: Prescribing Standards by Age Group
– Based on AACAP guidelines
– Medi-Cal requires TAR support info for:
0-5 years: more than 1 psychotropics
6-11 years: more than 2 psychotropics
12-17 years: more than 3 psychotropics
QIP Med Documents
• App. B: Parameters for Use of Psychotropic Medication
for Children & Adolescents – directs to 18-page
http://file.lacounty.gov/dmh/cms1_191102.pdf
• App. C: Challenges in Diagnosis and Prescribing
– Multiple situations that could raise concerns: ongoing
“rule outs,” multiple diagnoses & meds, changing > 1
med at a time, med use unsupported by literature, etc.
• App. D: Algorithm (Decision Tree) for Prescribing
– Basic principles in the use of medication
Over-Prescribing
• Issue complicated by ignorance and inflammatory
language
– Misunderstanding of “FDA approval”
– Notion that the way meds work is to slow & sedate
– Notion that serious side effects always or often occur
– “Powerful” makes a medication dangerous
– Notion of meds as “mind-altering”
8/14 SJ Mercury News
Articles & Editorial
• “Drugging Our Kids”
– Over the past decade, nearly 15% of Calif. foster
youth were given at least 1 psychotropic
– In 2013, of Calif. Foster youth taking a psychotropic,
12% received more than 1 at a time.
– Nearly ¼ of Calif. Foster youth received at least one
psychotropic = 3.5 x the rate for adolescents
nationwide
• How to interpret this?
Over-Prescribing
• Within days, DHCS changed policy on antipsychotics:
– TAR required for < age 18 (vs. < age 6)
– Requires lots of support information - but not specific
• Questions
– Positive outcomes?
– Negative outcomes?
– Is this discriminatory?
• Several bills have been proposed
Stimulants for ADHD
• Methylphenidate Group
– Ritalin, Ritalin-LA, Concerta, Methylin, Methylin-ER,
Metadate-CD) & Dexmethylphenidate (Focalin,
Focalin-XR)
– Block reuptake of DA
• Amphetamines Group
– Adderall, Adderall-XR, Vyvanse, Dextroamphetamine
– Block reuptake of DA and NE
Stimulants
• Duration
– Fast onset
– Some last 3-4 hours, some 6-8 hours, some 10-12
hours
• Forms - pills, capsules (can sprinkle some), liquid, patch
Stimulants
• Avoid with structural heart defect
• Common side effects:
– Poor appetite, weight loss, reduced growth rate
– headache, stomach ache, insomnia, tics
– agitation, slowed/subdued
– rebound hyperactivity
• Abusable
– No refills, can’t call in Rx
– No “high” from therapeutic doses
– No physical dependency
Strattera
(Atomoxetine)
• Advantages
– Not abusable
– Refillable prescriptions
– May last 24 hours
• Common side effects
– decreased appetite
– stomach ache, nausea, constipation
– dry mouth
• Low risk of suicidal ideation
Alpha Adrenergic
Agonists
• Clonidine
– Generic/Catapres: Fast-acting, last 4-6 hrs,
– Kapvay: extended release, 2 x daily dose
• Guanfacine
– Generic/Tenex: slow-acting, lasts 17 hrs
– Intuniv: ext. release, once daily dose
• Used for
– ADHD
– hyperarousal/anxiety
– insomnia
– tics
Alpha Adrenergic
Agonists
• Mechanism of action
– Stimulate alpha-2 adrenoreceptors in brainstem,
reducing sympathetic outflow from CNS
• Side effects
– Sedation
– lightheadedness
– emotional (crying easily)
– dry mouth
Antidepressants
– Used for depression and anxiety
– Limited evidence of benefit for depression in preteens
(big placebo response)
– FDA approval for children
• Depression - Fluoxetine age 8 & up
• OCD: Fluoxetine 7 & up, sertraline 6 & up,
Fluvoxamine 8 & up, Clomipramine 10 & up
– May take up to 6 weeks for a given dose to work
– Low risk of suicidal ideation
– For Major Depression, continue 9-15 months
– Taper to avoid withdrawal symptoms (irritability,
insomnia, flu-like symptoms)
SSRIs
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Selective Serotonin Reuptake Inhibitors
Usually first choice for depression or chronic anxiety
See handout for specific meds & doses
Side effects
– Headache
– Anxiety, agitation, insomnia
– Sedation
– Nausea, diarrhea, rash, weight change
– Reduced sex drive, impaired orgasm
– New suicidal ideation
– Mania
Non-SSRIs
• Bupropion (Wellbutrin-SR and –XL)
– May also reduce ADHD symptoms
– Less likely to reduce anxiety
– Headache, insomnia; avoid with seizure disorder
• SNRI’s
– Serotonin & Norepinephrine Reuptake Inhibitors
– Similar side effects as SSRIs but withdrawal of
greater concern
– Venlafaxine (Effexor-XR), Duloxetine (Cymbalta),
Desvenlafaxine (Pristiq), Levomilnacipran (Fetzima)
Non-SSRIs
• Tricyclics (e.g., imipramine, nortriptyline)
– Get EKG
– For depression, anxiety, ADHD, bedwetting, insomnia
– Watch for sedation, dry mouth, constipation
• MAO Inhibitors
– Seldom used in kids due to risk of severe
hypertension in combination with certain drugs, meds
and foods
• Augmentation: Abilify, Seroquel, TSH, Lithium,
Mood Stabilizers
• Atypical antipsychotics, anticonvulsants & lithium
(though “mood stabilizers” is often used to refer
only to lithium and anticonvulsants)
• Bipolar disorder
– Mania
– Depression
– Prevention
– Often need more than one med
• Poor modulation of anger/aggression
Antipsychotics
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Atypical (SGA) vs. Typical (FGA)
See handout for list of meds
Act at multiple receptor sites (especially atypicals)
Atypicals much more commonly used
– In part due to lower risk of tardive dyskinesia
– Can be very helpful for reactive aggression
– But concerns about:
• Overuse instead of using psychosocial
interventions
• Risk of increased weight, lipids and glucose
Antipsychotics
• Side effects include
– Sedation, lightheadedness, restlessness, stiffness,
tremor, headache, insomnia, nausea, anxiety, rash
• Weight gain, elevated lipids, elevated glucose & risk of
diabetes especially with atypicals
– Risk factors for cardiovascular disease
– Zyprexa, Clozaril > Seroquel, Risperdal> Abilify, Geodon
• Risperdal: galactorrhea, amenorrhea
• Clozaril: may cause seizures and interfere with WBC
production; very frequent blood draws required
• Tardive dyskinesia
Anticonvulsants
• Issues in selecting specific med
– Research evidence (most with Depakote, Lamictal)
– Need for regular labs (Depakote, Tegretol)
– Interactions with other meds (Depakote, Tegretol)
– Pregnancy risk (Depakote, Tegretol)
• Valproic Acid (Depakote, Depakene)
• Lamotrigine (Lamictal)
– Infrequent but potentially dangerous skin reaction
• Others: Carbamazepine (Tegretol), Oxcarbazepine
(Trileptal), Topiramate (Topamax), et al.
Lithium
• Seldom the first med we turn to in kids
• Mild side effects common
– Thirst, polyuria, tremor, nausea, weight gain
• May also affect cardiac function, reduce WBC,
thyroid and kidney function
– EKG and blood labs at baseline
– Blood tests every 3-6 months
• Overdose very dangerous
• Avoid in first trimester of pregnancy
Anxiolytics
• SSRIs and SNRIs
• Benzodiazepines
– Clonazepam (Klonopin), Lorazepam (Ativan),
alprazolam (Xanax), etc.
– Usually effective but highly abusable & addictive
– Best use for situational anxiety
• Buspirone (Buspar) – often ineffective
• Augmentation – e.g., with Risperdal in OCD
What Doctor Needs at
Med Appointment
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How is youth doing overall?
Recent stressors (good and bad)
Is the youth taking meds as prescribed?
Status of target symptoms
Side effects or other concerns?
Any significant plans (e.g., to leave program)
Roles of other adults
on treatment team
• Get what you need to know
– Meds and doses
– Reason for each med and any med change
– What to look for (have information sheets available)
• Between appointments
– Eyes and ears for doctor
– Contact doctor if necessary
– Help youth & family with questions and concerns
• Answer them
• Have them ask the psychiatrist