Download Psychotropic Medication

Behavioral Health
Medical Services
California Criminal Justice Reform:
Recidivism Reduction Training
Psychotropic Medication in Treatment Courts
Teresa Frausto, M.D.
Chief Medical Officer
April 13, 2016
www.SBCounty.gov
Disclaimer
Page 2
 No conflict of interest.
Behavioral Health
www.SBCounty.gov
Goals of Presentation
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 History of the mentally ill in corrections.
 Review common diagnosis and medication treatments.
 Discuss treatment challenges.
Behavioral Health
www.SBCounty.gov
Origins of the Community Mental Health SystemPage 4
 Deinstitutionalization of the severely mentally ill led to the
trans institutionalization to the jails and prisons.
 Funding from the cost savings achieved through the closures
of the state hospitals to the community mental health system
did not occur.
 Unlike services to persons with developmental disabilities, the
mental health system was never conceived as an “entitlement.”
 Mental health services were to be provided “to the extent
resources are available.”
Behavioral Health
www.SBCounty.gov
Origins of the Community Mental Health SystemPage 5
 Although deinstitutionalization was well intentioned, the
failure to provide treatment needs to the severely mentally ill
has turned this policy into one of the greatest social disasters
of the 20th century.
Behavioral Health
www.SBCounty.gov
Assembly Bill 109
Page 6
 Release of lower level offenders from the prisons back into the
community.
 Establishment of the Day Reporting Centers.
 Change in the population of the jails with more acute and
chronic medical and mental health problems.
Behavioral Health
www.SBCounty.gov
Psychotropic Medications
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 Most Commonly Used
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Antipsychotics;
Antidepressants;
Antianxiety (Anxiolytic);
Mood Stabilizers;
Psychostimulants; and
Others.
Behavioral Health
www.SBCounty.gov
Antipsychotics - Indications
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 Indications
• Psychotic symptoms
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Schizophrenia, Schizoaffective
Psychotic Symptoms
• Other applications
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Delirium/dementia
Substance induced psychosis/agitation
Severe aggression and violence behaviors
Severe Personality disorder
Behavioral Health
www.SBCounty.gov
Antipsychotics - Treatment of Symptoms
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 Psychotic Symptoms
• Positive symptoms
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Hallucinations, delusion, disorganization, Agitation
• Negative symptoms
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Alogia (speech), Avolition (drive), Anhedonia (pleasure), Apathy (flat
affect)
Behavioral Health
www.SBCounty.gov
Antipsychotic - Medications
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 Atypical Antipsychotics
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Clozapine (Clozaril)
Risperidone (Risperdal) >>> (Risperdal Consta)
Olanzapine (Zyprexa, Zydis)>> (Zyprexa Relprev)*
Quetiapine (Seroquel, Seroquel XR)
Ziprasidone (Geodon)
Aripiprazole (Abilify)
Paliperidone (Invega) >>> (Invega Sustenna)*
Iloperidone (Fanapt)*
Asenapine (Saphris)*
Lurasidone (Latuda)*
* Newer AP & Long Acting injectable AP
Behavioral Health
www.SBCounty.gov
Antipsychotic - Adverse Reactions
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Sedation, weight gain and cognitive dulling
Extrapyramidal symptoms (EPS)
Diabetes, Hypertension, increases in Cholesterol
Cardiac changes – for example arrhythmias
Behavioral Health
www.SBCounty.gov
Antidepressant - Indications
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 Indicators
• Depressive Disorders
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Major Depression
Dysthymia, Depression not otherwise specified
• Anxiety Disorders
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Panic disorders, Social Phobia
Post-traumatic Stress Disorder (PTSD)
• Other applications
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Eating disorders, Obsessive Compulsive Disorder
Premenstrual Dysphoric Disorder
Migraine, pain disorders, impulse control disorders
Behavioral Health
www.SBCounty.gov
Antidepressant - Treatment of Symptoms
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 Depressive Symptoms
• Pervasive depressed mood, Excessive guilt feelings, hopeless &
helplessness
• Psychomotor agitation or retardation
• Severe sleep disturbances
• Anhedonia, poor concentration
• Preoccupation with physical health
• Delusional / Suicide thoughts
Behavioral Health
www.SBCounty.gov
Antidepressant - Medications
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 Traditional Antidepressants*
• Monoamineoxidase Inhibitors(MAOI)
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Phenelzine (Nardil)
Tranylcypromine (Parnate)
• Tricyclic Antidepressants (TCAs)
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Amitryptyline (Elavil)
Imipramine (Tofranil)
Doxepin (Sinequan)
Clomipramine (Anafranil)**
* Able to measure therapeutic drug level
** Mainly for OCD
Behavioral Health
www.SBCounty.gov
Antidepressant – Medications (continued)
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 Traditional Antidepressants (continued)
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Nortryptyline (Pamelor)
Desipramine (Norpramin)
Protryptyline (Vivactil)
Trimipramine (Surmontil)
Amoxapine (Arsendin)
Behavioral Health
www.SBCounty.gov
Antidepressant – Medications (continued)
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 Newer Antidepressants
• Serotinin reuptake inhibitors (SSRIs)
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Fluoxetine (Prozac)
Paroxetine (Paxil, Paxil-CR)
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)
Fluvoxamine (Luvox / Luvox CR)*
Vortioxetine (Brintellix)
* Primarily for OCD
Behavioral Health
www.SBCounty.gov
Antidepressant – Medications (continued)
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 Newer Antidepressants (continued)
• Serotonin-Norepinephrine reuptake inhibitors
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Venlafaxine (Effexor, Effexor XR)
Duloxetine (Cymbalta)
Desvenlafaxine (Pristiq)
Levomilnacipran (Fetzima)
Behavioral Health
www.SBCounty.gov
Antidepressant – Medications (continued)
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 Other Atypical Antidepressants
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Mirtazapine (Remeron)
Bupropion (Welbutrin, Welbutrin SR, Wellbutrin XL)
Trazodone (Desyrel)
Vilazodone (Viibryd)
Vortioxetine (Brintellix)
Behavioral Health
www.SBCounty.gov
Antidepressant - Adverse Reactions
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Page 19
Orthostatic Hypotension
Dizziness, Tachycardia
Sedations, Weight gain
Hypertensive Crisis
Dry mouth, blurred vision, constipation
Conduction disturbances
Seizures
Tremors, Ataxia, Delirium (toxic level)
Erectile & ejaculatory dysfunctions
Behavioral Health
www.SBCounty.gov
Anti-Anxiety - Indications
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 Anxiety Disorders
• Panic Disorder, Phobias including Social Anxiety Disorder
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Generalized Anxiety Disorders, Acute Anxiety
Anxiety due to specific stressful life event(s)
 Other applications*
• Substance withdrawal
• As Hypnotic / Sedative
* Primarily for Benzodiazepines
Behavioral Health
www.SBCounty.gov
Anti-Anxiety - Treatment of Symptoms
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 Anxiety Symptoms
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Excessive worry & anxiety
Restlessness or feeling on edge
Easily Fatigability
Difficulty concentrating
Irritability, Muscle tension
Sleep disturbances
*Symptoms cause significant distress in daily social functioning
 Neuropsychiatric basis of treatment
• GABA receptors, Serotonin, Chloride ions
Behavioral Health
www.SBCounty.gov
Anti-Anxiety - Medications
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 SSRIs
• First line treatment for Anxiety disorders
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Fluoxetine (Prozac)
Paroxetine (Paxil, Paxil-CR)
Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)
Effexor, Effexor XR –FDA approved for Generalized Anxiety Disorder
Duloxetine (Cymbalta)
Behavioral Health
www.SBCounty.gov
Anti-Anxiety – Medications (continued)
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 Benzodiazepines
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Alprazolam (Xanax / Nirivum)
Clonazepam (Klonopin)
Diazepam (Valium)
Lorazepam (Ativum)
 Non-Benzodiazepine
• Buspirone (BuSpar)
• Hydroxyzine (Vistaril, Atarax)
Behavioral Health
www.SBCounty.gov
Anti-Anxiety - Adverse Reactions
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 SSRIs
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No immediate relieve of anxiety symptoms
Safer long term side effect profile
 Anxiolytic Benzodiazepines
• Most common
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Sedation, Ataxia, Dizziness, Cognitive impairment, Anterograde amnesiae
• Respiratory depression
• Abuse, Dependence
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Tolerance, Cross-tolerance, Withdrawal
Behavioral Health
www.SBCounty.gov
Mood Stabilizers - Indications
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 Indications
• Principle applications
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Treatment of Mania and Bipolar Disorders
Mood Disorders including Schizoaffective Disorder
Cyclothymia, Unipolar Depressions
• Other applications
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Impulse Control Disorders
Severe Personality Disorder
 Neuropsychiatric basis of treatment
• Second messenger system (Inositol, Arachidonic Acid, PhospholipaseA2)
Behavioral Health
www.SBCounty.gov
Mood Stabilizers - Medications
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 Mood stabilizers
• Standard mood stabilizers
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Lithium (Eskalith, Eskalith CR, Lithonate)
Valproate/ Divalproex (Depakene, Depakote)
Carbamazepine (Tegretol)
• Newer mood stabilizers
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Lamotrigine (Lamictal)
Topiramate (Topamax)
Oxcarbazepine (Trileptal)
Behavioral Health
www.SBCounty.gov
Mood Stabilizers - Adverse Reactions
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 Lithium
• Most common
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GI side effects ~ nausea and vomiting, Fine tremor, ‘Fuzzy feeling’
• Less common
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Renal…Polyuria, polydipsia, Diabetes Insipidus
Thyroid…Hypothyroidism
Dermatological…Rash & Acne
Neurological…muscle weakness, slurred speech (transient)
Cardiac…EKG changes, Edema
Hematological…Benign Leukocytosis
Behavioral Health
www.SBCounty.gov
Adverse Drug Reactions (continued)
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 Lithium toxicity
• Symptoms
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Nausea, Vomiting, Diarrhea, Coarse tremor, Ataxia, Headache, Slurred
speech, Confusion & Cardiac arrhythmia may occur
• Causes
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Reduced fluid intake, Increased fluid & electrolytes loss (Excessive
sweating, Diarrhea), Overdose
Drug interaction (Increased level by Diuretics, Non Steroidal Anti
Inflammatory)
Behavioral Health
www.SBCounty.gov
Neurotransmitter Related Reactions
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 Neurotransmitter related reactions*
• Anti-cholinergic reactions
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Dry mouth, Constipation, Urinary retention, Blurred vision
• Anti-alpha adrenagic reactions
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Orthostatic hypotension, Sedation, Techycardia
• Anti-histamine reactions
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Sedation, fatigue, Weight gain*, Hyperglycemia*
• Anti-dopamine reactions
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Parkinson like symptoms (masked faces, tremors, dystonia, shuffling gait)
Hyper Prolactinemia (Galactorrhea)
Akathisia
• Miscellaneous
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Hyper/hypothermia, photosensitivity, lower seizure threshold, rash, EKG
changes (QT interval), Agranulocytosis
*Anti-5HT1C ~ new warning for all Antipsychotic medications
Behavioral Health
www.SBCounty.gov
Treatment Challenges
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 How to get a mentally ill patient to:
• Take their medications?
• Stay on their medications?
Behavioral Health
www.SBCounty.gov
Treatment Challenges (continued)
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 What about forced medications?
Behavioral Health
www.SBCounty.gov
Treatment Challenges (continued)
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 When do you know the patient is stabilized on medications?
Behavioral Health
www.SBCounty.gov
Community Reentry
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 Development of a Release Team to ensure a warm hand off of
patients to community providers upon release.
 Increase in patients receiving follow up mental health and
substance use services in the community after release.
Behavioral Health
www.SBCounty.gov
Thank you!
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Teresa Frausto, M.D.
Chief Medical Officer
County of San Bernardino Department of Behavioral Health
Behavioral Health
www.SBCounty.gov