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Discontinuing Psychotropic Medication for California Foster Youth Mark D. Edelstein MD Board Certified Child and Adolescent Psychiatrist Medical Director, EMQ FamiliesFirst 2015 Presentation Topic: When & how psychotropic medications should be discontinue Audience: Foster youth and any adults involved in their care “Youth” refers to anyone < 18 years old Psychotropic Medication Psychotropic meds act in the brain to reduce symptoms of mood, cognition, behavior, etc. Psychological and environmental contributors are addressed with psychosocial interventions Examples of target symptoms of medication: ◦ ADHD: hyperactivity, impulsivity, inattention ◦ Depression, anxiety, labile mood, rage outbursts, manic episodes ◦ PTSD: Anxiety, intrusive memories, etc. ◦ Hallucinations, delusions, cognitive disorganization ◦ Severe insomnia Collaborative Medication Management Med management ◦ Initial and ongoing assessment ◦ Decision-making, including when & how to discontinue medicine Best practice: youth-centered & collaborative ◦ Youth – preferences; especially teens ◦ Prescriber (physician, NP or PA) – applies & shares expertise; offers options ◦ Judge – informed consent ◦ Other adults – caregivers & family, CPS, attorneys, probation officer, CASA et al. Psychotropic medication is usually needed for months or years Two reasons ◦ Most mental health conditions that we treat with meds persist for months or years ◦ Meds keep symptoms in check, they don’t “cure” (like blood pressure meds) Common exceptions ◦ Acute stress ◦ Effective therapy or coping skills for depression, anxiety or insomnia When to discontinue meds ? Max dose is not working Med is causing significant side effects (and changing dosage or timing is not an option) Second med is effective for same symptoms The med was unnecessary in the first place Irresponsible behavior: misuse of med, not coming to follow-ups, not getting labs, etc. Pregnancy: consider risk vs. benefit Youth has taken effective med for some time; can they do well now without it…? How could a med that worked no longer be needed? Brain may change over time ◦ Major depression less likely to return if medicine taken for 9-15 months ◦ ADHD-based hyperactivity/impulsivity commonly improve in adolescence Coping mechanisms may improve Environment may change ◦ Less stress or more support Prognosis may have been incorrect due to inaccurate diagnosis or heterogeneous disorder When to discontinue a med that has worked? Consider: ◦ Likelihood of recurrence and associated risks (including clinical course) ◦ Current and upcoming stressors ◦ Coping skills and supports ◦ Long-term risk of medication ◦ Youth and family preference Alternative: lower dose a little at a time How to discontinue meds Tapering is important for some meds Antidepressants – risk of withdrawal symptoms (insomnia, irritability, headache, flulike symptoms, etc.) Anticonvulsants (Depakote, Lamictal, Tegretol, Topamax, Trileptal et al.) – risk of seizure Adrenergic agonists (Guanfacine, Clonidine) – risk of high blood pressure Benzodiazepines – risk of withdrawal symptoms (insomnia, irritability, anxiety, etc.) Tapering Usually reduce dose gradually meds over a period of weeks (sometimes days) Prudent with other meds that are longacting, e.g., atypical antipsychotics Generally unnecessary with ◦ low dose ◦ short duration of treatment (weeks) Unnecessary with stimulants Parting thoughts If you take medicine ◦ Share your questions, concerns and preferences ◦ Talk with prescriber before stopping any medicine If you prescribe medicine ◦ Explain your reasoning to youth and family ◦ Offer recommendations and options If you are an adult in the life of a foster youth ◦ You can take part in the med management process