mental health in the schools: collaboration, communication and medications elizabeth reeve md...
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Mental Health in the Schools: Collaboration, Communication and Medications
Elizabeth Reeve MD
HealthPartners
Today’s Content
Collaboration Stakeholders Goals Problems
Communication Teachers, parents, psychologists, others
Diagnosis Medications in the classroom
Side effects, monitoring
Collaboration
One other thing- I was not comfortable passing out the ADHD forms you wanted filled out by teachers, coaches... I do not want him to be negativiely stereotyped any more than he already is. It doesn't help his self esteem. I'll bring in 4 of them, however, filled out by myself, my husband, and our daughters who've lived on their own now for yrs but know the situation quite well.
Collaboration
Stakeholders and Goals The individual student versus the school Whose best interest is being considered “The rights” of the student
IEP and 504s
Collaboration
Parent problems Fears of being “labeled” Unrealistic expectations for teachers and
MDs Physician problems
Lack of time to communicate with teachers Teacher schedule versus MD schedule
Lack of reimbursement
Collaboration
Teacher/School problems Lack of contact with the physician Pull between the needs of the school and
the needs of the individual student Medical goals may not be the same as the
academic goals Symptom treatment versus educational goals
Communication
Use of rating scales Release of information
How much should the school know Fears from the family that the school will
know too much The need for school data in order to
confirm diagnostic issues Social data, attention, learning
Diagnosis
School: ASD MD thinks they have ADHD and an
expressive language delay Physician: Anxiety and LD
School thinks they are oppositional and should be in an EBD room
Parental confusion? Does the diagnosis matter?
Medications
Basic principles Stimulants, SSRI’s, mood stabilizers,
antipsychotics What are the uses Side effects that impact the school setting
and/or learning
Basic Principles
There is no match between diagnosis and specific pharmacologic treatment Example: ADHD maybe treated with stimulants,
nonstimulants, antidepressants
Drug choice is made by the presence of a symptom, not by virtue of a diagnosis For example: antipsychotics may be used for:
augmentation in the treatment of anxiety and depression, psychosis, mood instability, aggression, explosive behavior or autism
So………
Identify the target symptom
Then choose the medication
The Seven Deadly Sins
Don’t treat Failure to set a target symptom Start meds but don’t adjust Start meds but adjust too much Setting the wrong expectations Failure to monitor Continuing medications with no efficacy
Medication Comparison: Methylphenidate Products
Medication Frequency Duration
Ritalin tid 2-4 hours
Focalin bid 2-5 hours
Ritalin SR qd or bid 5 hours
Ritalin LA qd 6-8 hours
Metadate CD qd 8 hours
Focalin XR qd 10 hours
Concerta qd 12 hours
Daytrana qd 14 hours
Medication Comparisons: Dexedrine Products
Medication Frequency Duration
Dexedrine bid or tid 5 hours
Adderall bid or tid 5 hours
Dex SR qd 6-9 hours
Adderall XR qd 9-10 hours
Lisdexamfetamine qd 12 hours
Ritalin® LA: Extended-release Delivery via SODAS™ Technology
SODAS™ is a trademark of Elan Corporation, Plc
Metadate CD
Adderall XR
Daytrana
Common Stimulant Side Effects
Appetite loss (expected) Insomnia Tics Headache Nausea Rebound irritability Growth suppression
Common Issues With Stimulants
Most children adolescents are under dosed OK to increase dose rapidly There is no efficacy difference between
various stimulants
Other Medications for Attention, Hyperactivity
Atomoxetine (Strattera) Non-stimulant Needs to be given everyday Takes weeks to work Can be refilled over the phone May be better for persons with anxiety Primary side effects
Sedation, nausea and vomiting, weight loss,
Other Medications for Attention, Hyperactivity
Clonidine or Tenex Need to be given everyday, multiple doses each day Take weeks to work Main side effect is sedation
Wellbutrin Given every day Risk of seizures Needs to be given 24/7 Takes weeks to work
Stimulant Issues in School
Students will not eat lunch Appetite suppression is expected
What time do the meds wear off? They don’t work if you don’t take them Bothersome tics Are there other reasons for attention
problems? Learning issues, anxiety
Selective Serotonin Reuptake Inhibitors
Fluoxetine (Prozac) Fluvoxamine (Luvox) Paroxetine (Paxil) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro)
SSRI’s
There is no efficacy difference between any of the SSRI’s All are potentially equally beneficial for
depression and anxiety Individuals have different responses but there
are not group efficacy differences The anxiety disorders that can be treated
with an SSRI include GAD, Separation Anxiety, Social Anxiety Disorder, OCD, Panic Disorder, PTSD. Elective Mutism
SSRI’s
All SSRI’s have the same general potential side effects Restlessness, akathesia Insomnia or fatigue Appetite changes, increased or decreased GI upset Headaches Sexual dysfunction
SSRI’s Serotonin syndrome
Can happen with any SSRI, as well as other me serotinergic effect such as venlafaxine, clomipramine, fenfluramine
Rapid onset Symptoms related to flood of extracellular 5HT May be frightening for the patient
trembling, shivering, fever, chills, clonus, hyperreflexia, may seem ataxic
Treat with support and 5HT blockers cyproheptadine and chlorpromazine
SSRI’s
SSRI withdrawal Paroxetine probably the worst Does not happen with fluoxetine
Characterized by flu-like syndrome Fever, shaking, fatigue, sweating, nausea,
diarrhea Usually starts within 24-36 hours and resolves
within 2-3 days, although may last longer Treat by restarting medication and slowing
down the taper
Choosing an SSRI
Knowledge of the parent about a particular drug
Side effect differences Weight gain, sedation, activation
Past history Cost
Other Antidepressants
Buproprion A great antidepressant but it does not help
anxiety Venlafaxine and duloxetine are both
serotonergic and noradrenergic reuptake inhibitors. Should help for both depression and anxiety
Trazodone and mirtazpine are used most often as sleep aids rather then antidepressants
SSRI Issues in School
Restlessness A common side effect and may show itself
as aggression or irritability Take weeks to work Emergence of suicidal thinking
Fact or fiction Assessing suicidality
Sexual dysfunction
Mood Stabilizers
Old Lithium Depakote Carbamazepine
New Oxcarbamazepine Gabapentin Lamotrogine Topiramate Others
Mood Stabilizers
A wide variety of uses Bipolar Disorder Augmentation in depression Explosive behavior Mood irritability Conduct disorder
Side Effects
Lithium Weight gain Acne Increased thirst and
urination May effect thyroid
and kidneys Cognitive impact
Depakote Weight gain Polycystic ovaries Osteoporosis
Mood Stabilizer
Topiramate “Dopamax” Sedation
Lamotrogine Rash
Antipsychotics: Old or New?
The Old Haldoperidol Thioridazine Thiothixene Proclorpromazine Perphenazine Fluphenazine
The New Clozapine Risperidone
Paliperidone Olanzapine Ziprasidone Aripiprazole Quetiapine
Differences Between Old and New Old
Less expensive Weight gain Elevated prolactin Tardive dyskinesia Few trials with kids
and adolescents
New More expensive Some may have less
weight gain Some may have
less prolactin change
May cause less tardive
More research in kids and adolescents
Metabolic Syndrome
All antipsychotics may cause an increase in cholesterol, triglycerides, and risk for diabetes
Draw baseline labs and record weight HgbA1c, fasting lipid panel
Check labs at least yearly, perhaps sooner if significant weight gain
Weight Gain
Weight gain contributes to low self esteem and medication non compliance
Medical consequences of excessive weight HTN, DM, sleep apnea, PCOS, joint and
back pain
Weight Gain for Each Drug
The literature suggests that the relative risks for diabetes, weight gain, and elevated lipids is as follows:Clozapine = Olanzapine > Risperidone =
Quetiapine > Aripiprazole = Ziprasidone The additional use of Depakote or lithium
may increase the risks
Issues At School With Antipsychotics
Weight gain Self esteem, lethargy, hunger Enlist the help of school nurse
NO SCHOOL LUNCH
Restlessness Sleepiness Other movement issues
School Lunch
The elementary school lunches average 821 calories per lunch with 30 percent fat
The biggest problem, is that students can choose food items from the a la carte lines that are not as balanced and nutritious as the actual school meal. “The dietary guidelines for the a la carte line hasn’t been updated since the 1970s,”
School Lunch
Updated recommendations 500 calories for breakfast and 650 for
lunch for kindergarten through fifth grade 550 for breakfast and 700 for lunch for kids
in sixth to eighth grade 600 for breakfast and 850 for lunch for high
school students
Questions????