With: David P. Kraft, MD, MPH, Psychiatrist Region I Mental Health Consultant Advisory Panel:

1. Managing Students on Psychotropic Medications in Job CorpsJob Corps Health and Wellness WebinarFebruary 11 & 12, 2010 With: David P. Kraft, MD, MPH, Psychiatrist Region I Mental Health Consultant Advisory Panel: Valerie Cherry, PhD, Principal Mental Health Consultant John Kulig, MD, MPH, Principal Medical Consultant Lois Sacher, RN, Principal Nursing Consultant

2. Topics Covered • How many students use psychotropic medications (PMs) in Job Corps? • What common mental health problems of students require the use of PMs? • Which PMs are used for common problems? • How can the health and wellness center and other center resources help students manage? • How can staff assist during various stages of a student’s stay? (examples)

3. Part 1 overview

4. How many students use PMs in Job Corps? • Data collection May-June 2008 • Questionnaire completed by HWM with assistance for 1 week during survey time • N = 122 centers completed survey • Total on-board strength = 40,470 • Total students on psychotropic meds = 2,339

5. PM Characteristics • Results showed: • Average percent students on PMs = 6.0% • Range from 0.0% to 27.0% of students on PMs • When did they start PMs? • Arrived on PMs = 3.0% (50% on PMs) • Resumed PMs = 1.0% (17% on PMs) • Started PM on center = 2.0% (33% on PMs) • How many PMs are they on? • One PM = 3.5% (65% on PMs) • 2-3 PMs = 1.8% (32% on PMs) • 4 or more PMs = 0.2% ( 3% on PMs) • Unknown = 0.5%

6. Dispensing, Prescribing, and Monitoring • Most students on PMs (55.5%) received PMs daily at the HWC, while others came weekly (26.9%), and still others (18.3%) kept PMs on self in room • Many center physicians and nurses expressed some concerns about inadequate training in prescribing and monitoring PMs, especially mood stabilizers, antipsychotics, and some other agents • Most center mental health consultants help evaluate (88.5%) and monitor (77.9%) students on PMs, though often feel inadequately trained about PMs

7. Consultation and Cost • Nationally, 22.1% of centers had a formal contract for psychiatric services, either with a psychiatrist, psychiatric nurse practitioner/physician’s assistant, or a clinic, usually to consult with center staff in selected cases, upon referral • Costs of PMs were often expensive, and paid either by student’s insurance (40.8%), including Medicaid, or center funds (45.5%). Note: 18.7% of students had lost their Medicaid due to relocation

8. Part 2 Uses of psychotropic medications

9. Uses of PMs in Job Corps Sources: Sadock BJ, Sadock VA. "Synopsis of Psychiatry: Behavioral Sciences/Clinical Psychiatry, Tenth Edition." Lippincott Williams and Wilkins, Philadelphia, PA, 2007. (I used the following page numbers for the added "Percent USA" chart numbers: "Depression 14-25%", p. 1259; "ADHD 4%", p. 1214; "Anxiety/Sleep 4-10%", p. 622; and "Psychotic/Impulsive Disorders 1%", p. 468. I don't think we need to include such page numbers, but could be persuaded otherwise.) American Psychiatric Association. "Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition" (DSM-IV). Washington, DC, American Psychiatric Association, 1994. (FYI, I used the original 1994 DSM-IV version, page 528, to verify the Bipolar number, but did not have the later "Text Revision" from 2000, to use in my documentation, though I'd be surprised if it was any different.)

10. Alternatives to PMs • Non-PM approaches used with various problems presented by students • Depression: Talk out sad feelings, regular exercise, Cognitive Behavior Therapy (CBT) • ADHD: Establish strict limits about non-stimulating environment when studying, keep lists to help memory, inform teacher of learning needs • Anxiety: Deep breathing, exercise, relaxation exercises, meditation, CBT. • Insomnia: Eliminate caffeine after supper, exercise, regular bedtime • Anger/explosive behavior: Count to 10, walk away before saying anything, time-out room, exercise

11. Part 3 Common Medications

12. Common PMs in Job Corps • Category of PMs Used • Antidepressants (ADP) 2.5% (33% on PMs) • Stimulants (ST) 2.0% (26% on PMs) • Mood Stabilizers (MS) 1.0% (12% on PMs) • Antipsychotics (APS) 1.0% (12% on PMs) • Hypnotics (HYP) 0.5% (8% on PMs) • Antianxiety Agents (ANX) 0.5% (7% on PMs) • Other (OTH) 0.1% (2% on PMs) Note: Full list in Appendix 1

13. Medication by Diagnosis S = Strong indication M = Moderate indication W = Weak indication

14. Medications by Category • Antidepressants (ADP)—depression and anxiety disorders, some impulsive disorders • SSRI—Selective Serotonin Reuptake Inhibitors • Fluoxetine (Prozac and others) • Sertraline (Zoloft and others) • Paroxetine (Paxil and others) • Fluvoxamine (Luvox and others) • Citalopram (Celexa and others) • Escitalopram (Luvox, related to citalopram)

15. Medications by Category • Antidepressants (ADP)—[continued] • SNRI—Serotonin Norepinephrine Reuptake Inhib • Venlafaxine ER (Effexor XR) • Duloxetine (Cymbalta) • Desvenlafaxine (Pristiq, related to venlafaxine) • Atypical Antidepressants • Bupropion (Wellbutrin SR, XR) • Mirtazapine (Remeron) • Nefazodone (Serzone) • Trazodone (Desyrel and others)

16. Medications by Category • Stimulants/others (ST)—for ADHD, atypical depression, narcolepsy • Stimulants: • Methylphenidate (Ritalin, Metadate, Concerta) • Amphetamine/dextroamphetamine salts (Adderall) • Dextroamphetamine (Dexedrine, Dextrostat) • Non-Stimulants, Novel Treatments • Atomoxetine (Strattera) • Modafinil (Provigil) • Antidepressants—for ADHD • Bupropion SR (Wellbutrin SR and others) • Desipramine (Norpramin, Aventyl and others) Note: Short acting forms can be easily abused to get high.

17. Medications by Category • Mood Stabilizers (MS)—for bipolar mood swings, severe depression, selective psychotic disorders, impulse control disorders, extreme anxiety • Lithium carbonate (Eskalith, Lithobid and others) • Anticonvulsants • Divalproex sodium (Depakote and others) • Carbamazepine (Tegretol, Equetro, Carbatrol) • Lamotrigine (Lamictal and others) • Oxcarbazepine (Trileptal) • Clonazepam (Klonopin and others)

18. Medications by Category • Antipsychotic agents (APS)—used for psychotic disorders, including: schizophrenia, with hallucinations, delusions and cognitive deficits; bipolar mood disorders; extreme anxiety disorders, like PTSD, where psychotic states may occur; and with impulsive/aggressive disorders, and autism. Also augments antidepressants in resistant depressions. • Note: Second generation APS have fewer side-effects on muscles, lower rate of tardive dyskinesia, but higher risk of metabolic syndrome, with excessive weight gain, abnormal lipid levels, and higher risk of diabetes

19. Medications by Category • Antipsychotic agents (APS)—[continued] • Second generation antipsychotics (SGAs): • Aripiprazole (Abilify) • Olanzapine (Zyprexa) • Paliperidone (Invega—related to risperidone) • Quetiapine (Seroquel) • Risperidone (Risperdal) • Ziprasidone (Geodon) • Risperidone depot (Risperdal Consta)—bimonthly injection • Paliperidone depot (Invega Sustenna)—monthly injection

20. Medications by Category • Hypnotic Agents (HYP)—for insomnia and related sleep disorders • Non-Specific Agents—non-addictive and often used first • Trazodone (Desyrel and others) • Diphenhydramine (Benadryl and others) • Quetiapine (Seroquel) • Mirtazapine (Remeron) • Sedatives • Triazolam (Halcion)—short half-life (2-4 hr) • Lorazepam (Ativan)—intermediate half-life (5-24 hr) • Clonazepam (Klonopin)—long half-life (19-60 hr) • Eszopiclone (Lunesta)—intermediate half-life (5-7 hr) • Zolpidem (Ambien)—short half-life (2.5 hr)

21. Medications by Category • Antianxiety Agents (ANX)—also known as minor tranquillizers or sedatives, useful for various anxiety states, high stress situations, that are episodic, or not adequately controlled with longer-term agents, such as antidepressants. • Note: Many ANX are potentially addictive, and should be controlled to avoid addiction or misuse by others.

22. Medications by Category • Antianxiety Agents (ANX)—[continued] • Benzodiazepines—potentially addictive • Lorazepam (Ativan and others)—half-life 8-24 hrs • Clonazepam (Klonopin and others)—half-life 19-60 hrs • Alprazolam (Xanax and others)—half-life 6-27 hrs • Diazepam (Valium and others)—half-life parent drug 14-80 hrs; active metabolite 30-200 hrs • Non-Benzodiazepines • Propranolol (Inderal)—half-life 2-6 hrs • Buspirone (Buspar)—half-life 2-11 hrs • Hydroxyzine (Atarax, Vistaril)—half-life 8-20 hrs

23. Part 4 Helping students manage their medication

24. Identify Signs and Symptoms of Problems • Highlight past history of problems at entry • During orientation and cursory exam, spot and discuss any possible problems with student • Refer students to CMHC if issues are discovered that you could not handle adequately • Help support student to find the help needed • For students who feel connected to you, maintain contact and give support

25. Educate Student on Safe Use of PMs • Most PMs take 14 days (2 weeks) to begin to work (except sedatives and stimulants which work faster) • New start-up of PMs give 5 days of side-effects; body will adjust if taken daily • Most medications are taken once a day, or may get withdrawal and start-up effects if skip doses

26. Educate Student on Safe Use of PMs • Black box warning for antidepressants, mood stabilizers and antipsychotics: May get suicidal ideas in first 2-4 weeks of use, before desired effects begin (no actual increase in completed suicides). Need to have student check in periodically. Recommend checking with student at least once a week for 4 weeks, then biweekly for a couple of months.

27. General Principles of Safe Use • Control amount of abuse-able PMs in residence halls, e.g. sedatives (benzo’s) and stimulants (limit to 1-2 days at a time, to discourage other students from taking them) • Use longer acting forms of stimulants, sedatives, and hypnotics, if possible (even though they are more expensive)

28. General Principles of Safe Use • Seek advice from HWC staff and consultants if adverse reactions • It is highly recommended that centers have a psychiatrist consultant, to help advise center HWM, MD, and CMHC about case management regarding possible problems • Warn student against stopping medications on own while in training program—save changes in medications for vacations, so not upset ability to learn when school is in session

29. Adverse Effects • With SSRI antidepressants (the most common of PMs), recognize SSRI-related adverse events and other symptoms • 3-12% of adolescents experience SSRI-related adverse events (very wide response range) • Common adverse events: • Behavioral activation or mania, or akathisia (ants in the pants) • Suicide ideation/self-harm/violent thoughts • Insomnia • Gastrointestinal distress (vomiting, diarrhea, stomach pain) • Headaches

30. Part 5 Monitoring students throughout their stay

31. At Arrival on Center • If student recently stopped medications, restart immediately (due to 2 week start-up) • Screen suspicious symptoms through CMHC, even if decided to re-start medications • If student stops medications, emphasize student’s responsibility for succeeding in program, and consequences if cannot study or learn successfully without the medications

32. During Training Program • If PMs stop working, consider raising dose, to overcome rapid metabolism of medications by liver • If loses control of symptoms, consider MSWR to allow student time to regain control with medication adjustment, and quick return to campus • If newly diagnosed depression or anxiety, have screened by CMHC, for non-medication skills and support during time before medications begin working

33. During Training Program • If medication adjustments are needed, inform staff with a “need-to-know” (NTK) how to help support student, after getting the student’s permission • If side effects inhibit learning for a part of the day (e.g., student falling asleep in morning class due to sedative side-effect of medications taken previous night), alert instructor to possible need to either change the student to a different class time, or to allow the student to catch up at a slower pace

34. Graduation or Separation • If on medication, develop plan to transfer medication/therapy services to community where student plans to live • Help students learn process of life-long care for own needs • Consider using JAN to help with transition planning and arrangements

35. Summary • An average of 6% of students in Job Corps are prescribed Psychotropic Medications (range: 0 to 27%, by center) • Most Center Physicians, NPs & PAs prescribe basic medications while the student attends Job Corps • Some centers (22%) have psychiatric consultant services. More should consider this

36. Summary • Psychiatric problems of Job Corps students on PMs are similar to age mates • Highest proportion on PMs with depression (33%), representing 2.5% of students—lower than USA prevalence of 14-25% older adolescents • Similar proportion on PMs with ADHD (26%), representing 2% of students—lower than 4% USA • Same proportions with psychotic and bipolar disorders as population (1% for each) • Lower proportions on PMs for anxiety and sleep disorders (1.5%) than in population (4-10%)

37. Summary • Education about PMs (e.g., the 5-14 rule) and how to use, is helpful for all students, to improve compliance and success in Job Corps • Assisting students needing accommodations for psychiatric problems will help success at JC and after graduation • Teamwork with other center staff can prevent or minimize most problems with PMs

38. References • Job Corps, PRH, TAG-H: Mental Health Disabilities [on Job Corps website] • Maxmen JS, Kennedy SH, McIntyre RS. Psychotropic Drugs: Fast Facts. New York, W. W. Norton & Company, 2008.

39. Appendix 1 Medications by category

40. Medications by Category • Antidepressants (ADP)—depression & anxiety disorders, some impulsive disorders • SSRI—Selective Serotonin Reuptake Inhibitors • Fluoxetine (Prozac & others) • Sertraline (Zoloft & others) • Paroxetine (Paxil & others) • Fluvoxamine (Luvox & others) • Citalopram (Celexa & others) • Escitalopram (Luvox, related to citalopram)

41. Medications by Category

42. Medications by Category • Medications by Category • Antidepressants (ADP)—depression & anxiety disorders, some impulsive disorders • SSRI—Selective Serotonin Reuptake Inhibitors • Fluoxetine (Prozac & others) • Sertraline (Zoloft & others) • Paroxetine (Paxil & others) • Fluvoxamine (Luvox & others) • Citalopram (Celexa & others) • Escitalopram (Luvox, related to citalopram)

43. Medications by Category • Medications by Category • Antidepressants (ADP)—[continued] • SNRI—Serotonin Norepinephrine Reuptake Inhib • Venlafaxine ER (Effexor XR) • Duloxetine (Cymbalta) • Desvenlafaxine (Pristiq, related to venlafaxine) • Atypical Antidepressants • Bupropion (Wellbutrin SR, XR) • Mirtazapine (Remeron) • Nefazodone (Serzone) • Trazodone (Desyrel & others)

44. Medications by Category • Antidepressants (ADP)—[continued] • TCAs—Tricyclic Antidepressants • Amitriptyline (Elavil & others) • Clomipramine (Anafranil) • Doxepin (Sinequan, & others) • Imipramine (Tofranil & others) • Desipramine (Norpramin & others) • Nortriptyline (Aventyl & Pamelor)

45. Medications by Category • Antidepressants (ADP)—[continued] • MAOIs—Monoamine Oxidase Inhibitors. Note: need close dietary monitoring or can be fatal. (Seldom used unless all other ADPs failed.) • Phenelzine (Nardil) • Selegiline (Emsamtransdermal patch)—[NEW] • Tranylcypromine (Parnate)

46. Medications by Category • Stimulants (ST)—for ADHD, atypical depression, narcolepsy. • Stimulants, long-acting: • Amphetamine/dextroamphetamine (Adderrall XR) • Dexmethylphenidate SR (Focalin XR) • Lisdexamfetamine (Vyvanse) • Methylphenidate SR (Concerta ER. Metadate ER, Ritalin XR, and others) • Methylphenidate transdermal system (Daytrana)

47. Medications by Category • Medications by Category • Stimulants (ST)—[continued] • Stimulants, short-acting: • Methylphenidate (Ritalin, Metadate, Concerta) • Amphetamine/dextroamphetamine salts (Adderall) • Dextroamphetamine (Dexedrine, Dextrostat) • Non-Stimulants, Novel Treatments • Atomoxetine (Strattera) • Modafinil (Provigil) • Antidepressants—for ADHD • Bupropion SR (Wellbutrin SR & others) • Desipramine (Norpramin & others)

48. Medications by Category • Mood Stabilizers (MS)—for Bipolar mood swings, severe depression, selective psychotic disorders, impulse control disorders, extreme anxiety. • Lithium carbonate (Eskalith, Lithobid and others) • Anticonvulsants • Divalproex sodium (Depakote and others) • Carbamazepine (Tegretol, Equetro, Carbatrol) • Lamotrigine (Lamictal and others) • Oxcarbazepine (Trileptal) • Clonazepam (Klonopin and others)

49. Medications by Category • Mood Stabilizers (MS)—[continued] • Antipsychotic Medications • Chlorpromazine (Thorazine & others) • Haloperidol (Haldol & others) • Aripiprazole (Abilify) • Olanzapine (Zyprexa) • Paliperidone (Invega) • Quetiapine (Seroquel) • Risperidone (Risperdal) • Ziprasidone (Geodon)

50. Medications by Category • Antipsychotic agents (APS)—used for psychotic disorders, including: schizophrenia, with hallucinations, delusions & cognitive deficits; bipolar mood disorders; extreme anxiety disorders, like PTSD, where psychotic states may occur; and with impulsive/aggressive disorders, & autism. Also augments antidepressants in resistant depressions. • Note: Second generation APS have fewer side-effects on muscles, lower rate of Tardive Dyskinesia, BUT higher risk of Metabolic Syndrome, with excessive weight gain, abnormal lipid levels, & higher risk of diabetes.