with: david p. kraft, md, mph, psychiatrist region i mental health consultant advisory panel:
DESCRIPTION
Managing Students on Psychotropic Medications in Job Corps Job Corps Health and Wellness Webinar February 11 & 12, 2010. With: David P. Kraft, MD, MPH, Psychiatrist Region I Mental Health Consultant Advisory Panel: Valerie Cherry, PhD, Principal Mental Health Consultant - PowerPoint PPT PresentationTRANSCRIPT
Managing Students on Psychotropic Medications in Job Corps
Job 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 ConsultantLois Sacher, RN, Principal Nursing Consultant
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)
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OVERVIEWPart 1
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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
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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%
04/21/23 5
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
04/21/23 6
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
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USES OF PSYCHOTROPIC MEDICATIONS
Part 2
04/21/23 8
Problem Percent JC students Percent US
Depression 2.5% 14-25%
Attention Deficit/Hyperactivity Disorder (ADHD)
2.0% 4%
Anxiety or Sleep Disorders
1.5% 4-10%
Psychotic/Impulsive Disorders
1.0% 1%
Bipolar Mood Disorder
1.0% 1%
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.)
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
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COMMON MEDICATIONSPart 3
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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)
04/21/23 12
Note: Full list in Appendix 1
Medication by Diagnosis
ADepres
Stim MoodS APsych Hypnotc
ANX
Depress S W M W W S
ADHD M S W W M
Bipolar W S S M M
Psychotic
W M S W W
Impulsive
M S S M M
Anxiety S M M S
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S = Strong indication M = Moderate indication W = Weak indication
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)
04/21/23 14
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)
04/21/23 15
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)
04/21/23 16
Note: Short acting forms can be easily abused to get high.
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)
04/21/23 17
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
04/21/23 18
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
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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)
04/21/23 20
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.
04/21/23 21
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
04/21/23 22
HELPING STUDENTS MANAGE THEIR MEDICATION
Part 4
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Identify Signs and Symptoms of Problems
Highlight past history of problems at entryDuring 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 neededFor students who feel connected to you,
maintain contact and give support
04/21/23 24
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
04/21/23 25
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.
04/21/23 26
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)
04/21/23 27
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
04/21/23 28
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
04/21/23 29
MONITORING STUDENTS THROUGHOUT THEIR STAY
Part 5
04/21/23 30
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
04/21/23 31
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
04/21/23 32
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
33
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
04/21/23 34
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
04/21/23 35
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%)
04/21/23 36
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
04/21/23 37
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.
04/21/23 38
MEDICATIONS BY CATEGORY
Appendix 1
04/21/23 39
04/21/23 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)
Medications by Category
04/21/23 41
ADepres
Stim MoodS APsych Hypnotc
ANX
Depress S W M W W S
ADHD M S W W M
Bipolar W S S M M
Psychotic
W M S W W
Impulsive
M S S M M
Anxiety S M M S
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)
04/21/23 42
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)
04/21/23 43
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)
04/21/23 44
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 (Emsam transdermal patch)
—[NEW] Tranylcypromine (Parnate)
04/21/23 45
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)
04/21/23 46
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)
04/21/23 47
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)
04/21/23 48
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)
04/21/23 49
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.
04/21/23 50
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
04/21/23 51
Medications by Category
Antipsychotic agents (APS)—[continued] First Generation Antipsychotics (FGAs)
Chlorpromazine (Thorazine & others) Haloperidol (Haldol & others) Fluphenazine (Prolixin) Loxitane (Loxitane) Perphenazine (Trilafon) Thioridazine (Mellaril) Thiothixene (Navane) Haloperidol Depot (Haldol Decanoate)—monthly
injection Fluphenazine Depot (Prolixin Decanoate—
bimonthly injection
04/21/23 52
Medications by Category
Hypnotic Agents (HYP)—for insomnia and related sleep disorders Triazolam (Halcion)—short half-life (2-4 hr) Temazepam (Restoril)—intermediate half-life (12 hr) Flurazepam (Dalmane)—long half-life (67 hr) Eszopiclone (Lunesta)—intermediate half-life (5-7
Hr) Zolpidem (Ambien)—short half-life (2.5 hr) Zaleplon (Sonata)—ultra short half-life (1-2 hr) Ramelteon (Rozerem)—short half-life (0.8-2.6 hr),
melatonin base
04/21/23 53
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.
04/21/23 54
Medications by Category
Antianxiety Agents (ANX)—[continued] Benzodiazepines—potentially addictive.
Lorazepam (Ativan & others)—half-life 8-24 hrs Clonazepam (Klonopin & othrs)—half-life 19-60
hrs Alprazolam (Xanax & others)—half-life 6-27 hrs Diazepam (Valium & 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
04/21/23 55
Medications by Category
Antianxiety Agents (ANX)—[continued] Anticonvulsants
Divalproex sodium (Depakote) Gabapentin (Neurontin) Pregablin (Lyrica) Tiagabine (Gabitril)
TCA Antidepressants Clomipramine (Anafranil)
04/21/23 56
Medications by Category
Antianxiety Agents (ANX)—[continued] SSRI Antidepressants
Citalopram (Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox & others) Paroxetine (Paxil) Sertraline (Zoloft)
SNRI Venlafaxine (Effexor) Duloxetine (Cymbalta)
04/21/23 57