Welcome

1. Psychopharmacology :Monitoring for the intended and the unintended effects of psychotropic medications.

2. Welcome My goal today is to talk about different classes of medications that you might see prescribed for children with mental disorders.

3. Barbara Noordsij APRN, ND, PMHNP, BC Psychiatric Mental Health Nurse Practitioner for Washington County Mental Health Services Inc. No, I do not work for or participate in any pharmaceutical research or development. Never have. I am biased about kids and horses.

4. Here we go…

5. If you need a break take a break. 1:00 - 2:30 PM 2:45 - 4:15 PM

6. This next slide shows that approximately half, 50.6 % of children with mental disorders had received treatment for their disorder within the past year. There were some differences between treatment rates depending on the category of mental disorder. Children with anxiety disorders were the least likely (32.2 percent) to have received treatment in the past year.

8. Prescribed psychotropic medications are not being misused or overused among U.S. youth, according to a study using nationally representative data sponsored by NIMH. This study was published December 3, 2012. Archives of Pediatric and Adolescent Medicine.

9. Among those youth who met criteria for any mental disorder, 14.2 percent reported that they had been treated with a psychotropic medication. Teens with ADHD had the highest rates of prescribed medication use at 31 percent, while 19.7 percent of those with a mood disorder like depression or bipolar disorder were taking psychotropic medication. Among those with eating disorders, about 19 percent were taking a psychotropic medication, and 11.6 percent of those with anxiety disorders reported taking medication. Very few youth reported use of antipsychotic medications. They were most frequently used by youth with severe bipolar disorder (1.7 percent) or a neurodevelopmental disorder such as autism (2.0 percent). Approximately 2.5 percent of teens without a diagnosed mental disorder were prescribed a psychotropic medication. Among these youth, 78 percent reported having a previous mental or neurodevelopmental disorder and associated psychological distress or impairment.

10. Neuron

11. The synapse, where it all happens

12. A word about genetics It is not nature versus nature It is not genes versus environment It is Genetics and the Environment It is Vulnerability

13. Etiology of mental illness Prenatal environment Attachment Temperament Parenting Exposure All of these interact with a persons genetics , vulnerabilities, phenotype and leads to illness.

14. Medications

15. Treatment with medications Some medications treat the underlying cause of the illness. Some medications treat symptom clusters of the illness. Some medications really just try to make the client more available for the real treatment such as your behavioral strategies and support. (NAMI video clips)

16. Considerations for all medications Consent What is the parents perspective? Do they want their child on medications. Do they feel that the prescriber knows their child well enough to make recommendations. “ AKA” trust.

17. More considerations How to initiate the drug How to terminate the drug Cautions to clients Contraindications to the use of this drug Instructions Drug interactions Food interactions

18. More considerations Monitoring the medication after starting the medication Frequency of follow-up Is it approved for use in children?

19. Stimulants Early in treatment there are some side effects that may disappear over time. Fatigue, anorexia or no appetite, headache, stomach ache, sleep problems, irritability, dysphoria If severe, dose may be too high

20. Stimulant dose is too high? May cause dysphoria, depression, irritability Moodiness when dose wears off The child may seem to be too flat Insomnia that is worse Significant weight loss

21. Continued adverse effects of stimulants Cardiovascular (tachycardia, hypertension/hypotension, palpitations) Exacerbate psychosis or mania Lower seizure threshold (not usually significant risk, can be used cautiously in patients with epilepsy)

22. Stimulants -what we want to know: Is the child more focused and attending. Is the child experiencing side effects. Is the child getting the medication regularly.

23. Stimulants, some more common drug names Adderall amphetamine Adderall XR Concerta methylphenidate Focalin (dexmethyphenidate) Focalin XR Metadate methylphenidate Ritalin methylphenidate Vyvance lisdexamfetamine

24. Another class of medications for ADHD. In addition these medications may also be used for aggressive behavior which may be due to hypervigilance, or emotionally reactive children. They are…

25. Alpha-adrenergic medications These medications are alpha – 2- noradrenergic receptor agonists (stimulating agents) that inhibit endogenous release of nor -epinephrine in the brain. Clonidine hydrochloride (clonidine) Guanfacine (Tenex, Intuniv)

26. Alpha adrenergic medications Adverse effects of these medications concern the effects these medications can have on the cardiovascular system. Lower blood pressure Slowed heart rate or heart block

27. One more medication for ADHD, which is in a group unto itself …

28. Strattera ,atomoxetine Chemically similar to older tricyclic medications. (in the old days we used imipramine for kids with ADHD a tricyclic) Adverse effects: Sedation Cardiovascular (electrocardiogram)

29. Signs a child is having cardiovascular issues. Can’t catch his breath. Feels like his heart is pounding. Passes out or is dizzy. Describes a “funny feeling” and points to his chest. Color is blue or dusky.

30. Depression Recently published results from the National Comorbidity Study–Adolescent Supplement reveal a lifetime prevalence of major depressive disorder or dysthymia of 11.2% of 13- to 18-year-olds, with a 3.3% lifetime prevalence of a severe depressive disorder in that same age group. The 2008 National Survey on Drug Use and Health, sponsored yearly by the Substance Abuse and Mental Health Services Administration, shows the prevalence of depression among 12- to 17-year-olds to be 8.3%, with girls showing 3 times the prevalence as boys. One-year prevalence rates for major depression are approximately 2% in childhood and 4% to 7% in adolescence.

31. Suicide risk is significantly increased in youth with depressive disorders and is the third leading cause of death in adolescents. Data published by the Centers for Disease Control and Prevention report that over a 1-year period of time studied; 13.8% of American adolescents considered killing themselves 10.9% had made plans, and 6.3% actually reported attempting suicide.

32. Antidepressant medications SSRI’s -serotonin reuptake inhibitor Common initial side effects go away after a couple of weeks. If severe side effects may need to slow the titration. They are: nausea, stomach upset, decreased appetite, and headache.

33. Anti-depressant medications = Anti-Anxiety medications

35. SSRI’s Prozac, fluoxetine Paxil, paroxetine Zoloft, sertraline * Lexapro, escitalopram Celexa, citalopram *

36. More on Antidepressants Older medications “amines” The tricyclic's: imipramine, amitriptyline, clomipramine, desipramine. Concerns re: cardiac reactions: chest pain, shortness of breath, heart racing, dizziness. Dangerous risk of overdose. Heart block which is difficult to reverse with medications.

37. Antidepressants- what we want to know These medications take several weeks to work. A bad reaction would be a sudden change in personality or behavior. Off the charts, out of the norm. Euphoria, happiness a sudden change could mean mania. If what you see, is just a continuation of target behaviors, it may just mean that an effective dose has not been achieved.

38. AntidepressantsMonoamine Oxidase Inhibitors MAOI’s Nardil, phenelzine Parnate ,tranylcypromine Food and OTC drug interactions major concern Which can cause a hypertensive crisis. Tend to be used rarely. Generally for treatment resistant depression and anxious individuals

39. Antidepressants Dual agents Effexor ,venlafaxine Cymbalta, duloxetine Pristiq, desvenlafaxine Work on two receptors

40. Dual agent usually implies that the medication is effective at two receptor sites.

41. Dual agents Adverse effects, similar to SSRI’s andIncreased concern about sensitivity to cardiovascular side effects, increased BP, agitation, sleep issues

42. Anxiety a little more on this. • Buspirone. This anti-anxiety medication may be used on an ongoing basis. As with most antidepressants, it typically takes up to several weeks to become fully effective. A common side effect of buspirone is a feeling of lightheadedness shortly after taking it. Less common side effects include headaches, nausea, nervousness and insomnia.

43. Anxiety and benzodiazepines; Ativan lorazepam, klonopin clonazepam For short-term relief of anxiety symptoms. Benzodiazepines are generally only used for relieving acute anxiety on a short-term basis. school phobia, panic attacks severe Concerns - Habit forming Other signs of mis use: drowsiness, reduced muscle coordination, and problems with balance and memory.

44. Mood medications Essentially two categories Lithium And Anticonvulsants

45. Lithium Lithium is a salt. So anything that upsets a fluid and salt balance in the body can increase risks. Lithium has a narrow therapeutic range. To low – it doesn’t work To high – toxic

46. Signs of lithium toxicity If you see this (as below) , hold the dose, until you consult with a practitioner. Consult with provider immediately or take the child to the emergency room. “looks drunk” ataxia unsteady gait, slurring of words, confusion, lethargy or tremors

47. Treatment with lithium and renal failure risks Recently, McKnight and colleagues published a meta-analysis encompassing 5988 abstracts and 385 studies from 1966 to 2010, concluding an absolute risk of renal failure of 0.5% (18/3369 patients).

48. Anticonvulsants In general: When these medications are started they cause some cognitive slowing and tiredness. Usually this will abate as time goes by and it may take a few weeks. If severe consult with the provider.

49. Anticonvulsants Depakote, valproic acid, divalproex Tegretol, carbamazepine Trileptal, oxycarbamazepine Topomax , topiramate Neurontin, gabapentin Lamictal , lamotrogine

50. Anticonvulsants Several of them have a serious rash that can be associated with the start of treatment. Any rash in the first few weeks of treatment is a concern and should be evaluated. Do not administer additional medication until it is evaluated by a provider.