Managing and Accommodating Students on Psychotropics and Other Medications that Affect Mental Health

Job Corps National Health and Wellness ConferenceLas Vegas, Nevada

April 15, 2009

David P. Kraft, MD, MPHRegion I Mental Health Consultant

John Sommers-Flanagan, Ph.D.Center Mental Health ConsultantTrapper Creek Job Corps Center

Objectives

1. Psychotropic medications (PMs) most used by Job Corps students

2. Describe how to manage safe use of PMs in Job Corps

3. Describe ways to case manage students who need PMs

4. Describe empowerment strategies for student who need PMs

5. Example-Hear Trapper Creek students engage in medication monitoring

6. Possible accommodations for students on PMs

2

1. PMs Most Used by Job Corps Students (Spring 2008)

• Study—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

3

1. PMs Most Used by Job Corps Students (Spring 2008)

• Results showed– Average percent students on PMs = 6%

– Range from 0% to 27% on PMs

– When did they start PMs?– Arrived on PMs = 3% (50% on PMs)– Resumed PMs = 1% (17% on PMs)– Started PM on center = 2% (33% on PMs)

– How many PMs are they on?– One PM = 3.5% (65% on PMs

)– 2-3 PMs = 1.7% (32% on

PMs)– 4 or more PMs = 0.3% ( 3% on PMs) 4

1. PMs Most Used by Job Corps Students (Spring 2008)

• Category of PMs Used– Antidepressants 2.5% (33% on PMs)– Stimulants 2% (26% on PMs)– Mood Stabilizers 1% (12% on PMs)– Antipsychotics 1% (12% on PMs)– Hypnotics 0.5% (8% on PMs)– Antianxiety Agents 0.5% (7% on PMs)– Other 0.1% (2% on PMs)

5

1. PMs Most Used by Job Corps Students (Spring 2008)

• Funding Sources– Insurance (include Medicaid)41%

• [Lost Medicaid due to move = 19%]

– Center Funds 46%– Free Samples 7%– Other (e.g., grants) 2%

6

2. Describe How to Manage Safe Use of PMs in Job Corps

• Principles of safe use of Psychotropic Medications– Most PMs take 2 weeks to begin to

work (except sedatives and stimulants)– New start 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

7

2. Describe How to Manage Safe Use of PMs in Job Corps

• Principles of safe use of PMs (cont’d)

– “Black-box”: for antidepressants, mood stabilizers and antipsychotics, may get some suicidal ideas in first 2-4 weeks of use, before desired effects begin (NOT actually increase completed suicides). Need to have student check in periodically.

– Use of PMs by Problem (Appendix 1)

8

2. Describe How to Manage Safe Use of PMs in Job Corps

• General principles of safe use in JC– Control amount of abusable PMs in

residence halls, e.g., sedatives (benzo’s) and stimulants (limit to 1-2 days, to keep other students from taking them)

– Use longer acting forms of sedatives and hypnotics, if possible (more expensive)

9

2. Describe How to Manage Safe Use of PMs in Job Corps

• General principles of safe use (cont’d)

– Seek advice from HWC staff if adverse reactions

• All centers should have psychiatrist consultant, regarding possible problems, to advise center MD about case management

– 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

10

2. Describe How to Manage Safe Use of PMs in Job Corps

• Non-PM approaches to problems– Depression: talk out sad feelings, regular

exercise, Cognitive Behavior Therapy (CBT)

– Anxiety: deep breathing, exercise, relaxation exercises, meditation

– Insomnia: eliminate caffeine after supper, exercise, regular bedtime

– Anger/explosive behavior: “count to 10”, walk away before saying anything, time-out room, exercise 11

2. Describe How to Manage Safe Use of PMs in Job Corps

• Non-PM approaches to problems (cont’d)

– Psychotherapy methods, short-term:• Cognitive Behavior Therapy (CBT)• Dialectical Behavior Therapy (DBT)• Relationship Therapy• Reality Therapy• Psychosocial Therapy• Brief Psychodynamic Psychotherapy

12

3. Describe Ways to Case Manage Students who Need PMs

• At initial 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 still needs medications, but cannot study successfully without them

13

3. Describe Ways to Case Manage Students who Need PMs

• During Training Program– If PMs stop working, consider raising dose, to

overcome rapid metabolism of medications by liver

– If loses control, consider MSWR to allow time to regain control with medication adjustment

– If newly diagnosed depression or anxiety, have screened by CMHC, for support

– If medication adjustments are needed, inform staff with a “Need-to-Know” (NTK), with student’s permission, to help support student

14

3. Describe Ways to Case Manage Students who Need PMs

• Planning for Graduation/Separation– If on medication, develop plan to

transfer medication/therapy services to community where he/she moves

– Help student learn process of life-long care for own needs

– Consider using JAN to help with transition planning and arrangements

15

4. Describe Empowerment Strategies for Students who Need PMs

• Helping students manage medications– CMHC and “Introduction to Center Life”

integration• Non-coercive approach• A pill is not a skill• You are responsible for your behaviors• Counseling and intern resources (180 extra hours

of counseling each semester)

– Initial physician visit– Medication explanations and framing

16

4. Describe Empowerment Strategies for Students who Need PMs

• SSRI-related adverse events and other target symptoms– 3-12% of adolescents experience SSRI-

related adverse events (very wide response range)

– Common adverse events:• Behavioral activation or mania or akathisia• Suicide ideation/self-harm/violent thoughts• Insomnia• Gastrointestinal distress (vomiting, diarrhea,

pain)• Headaches

17

4. Describe Empowerment Strategies for Students who Need PMs

• Listening to students and their experiences– General motivational interviewing

questions– Specific symptom-based questions– Reflecting and amplifying student

contributions to symptom reduction

18

4. Describe Empowerment Strategies for Students who Need PMs

• Differential Activation Theory– Students with a history of suicidality

may be more prone to having their symptoms reactivated

– A constructive interview protocol can help activate and reactivate personal strengths and coping resources

19

4. Describe Empowerment Strategies for Students who Need PMs

• Communication and case management strategies– Establish a collaborative and personal

responsibility mind-set in students and staff as described

– Adhere to FDA recommendations for supportive weekly monitoring first four weeks and biweekly monitoring the next four weeks

20

4. Describe Empowerment Strategies for Students who Need PMs

• Communication and case management strategies (cont’d)

– The four reality therapy (choice theory and personal responsibility) questions

• What do you want?• What are you doing?• Is it working?• Should you make a new plan?

21

5. Example-Hear Trapper Creek Students Engage in Medication Monitoring

Video clips

22

6. Possible Accommodations for Students on Psychotropic Medications

• Utilizing the IDT/reasonable accommodation team to plan for success with students on PMs

23

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.

24

Appendix 1: PMs used for Various Problems

• Depression– Selective Serotonin Reuptake Inhibitors (SSRIs)—

fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox), trazodone (Desyrel)

– Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)—venlafaxine ER (Effexor XR), duloxetine (Cymbalta), desvenlafaxine (Pristiq)

– Atypical Antidepressants—bupropion (Wellbutrin), doxepin (Serzone)

– Tricyclic Antidepressants (TCAs)—amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramine), etc.

25

Appendix 1: PMs used for Various Problems (cont’d)

• Anxiety– Immediate: Benzodiazepines ( BDZ)—

lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium)—effective immediately, but addictive

– Long Term: SSRIs, buspirone, SNRIs, TCA’s, antihistamines (hydroxyzine, diphenhydramine)

26

Appendix 1: PMs used for Various Problems (cont’d)

• Bipolar Mood Swings– Lithium carbonate (needs blood tests)– Anticonvulsants: divalproex (Depakote),

carbamazepine (Tegretol, Carbatrol), lamotrigine (Lamictal), oxcarbazepine (Trileptal), topiramate (Topamax)

– Antipsychotics: olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), risperidone (Risperdol), paliperidone (Invega), clozapine (Clozaril)

27

Appendix 1: PMs used for Various Problems (cont’d)

• Psychotic Disorders– Antipsychotics: olanzapine (Zyprexa),

quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), risperidone (Risperdol), paliperidone (Invega), clozapine (Clozaril)

– Anticonvulsants: divalproex (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), oxcarbazepine (Trileptal), topiramate (Topamax)

28

Appendix 1: PMs used for Various Problems (cont’d)

• Impulsive/Explosive Disorders – SSRIs– Antipsychotics– Lithium– Beta-blockers—propranolol (Inderal)

[high dose], nadolol

29

Appendix 1: PMs used for Various Problems (cont’d)

• Attention Deficit/Hyperactivity Disorder– Antidepressants: fluoxetine (Prozac),

buproprion (Wellbutrin), desipramine– Stimulants: methylphenidate (Ritalin),

amphetamine salts (Adderall), dextroamphetamine (Dexedrine),

– Stimulants: long-acting forms (Adderall-XR, Focalin-XR, Concerta-ER, Metadate-ER, Daytrana patch, Vyvanse)

– Non-Stimulants: atomoxetine (Strattera), modafinil (Provigil)

30

Appendix 1: PMs used for Various Problems (cont’d)

• Sedative/Hypnotics– Benzodiazepines ( BDZ)—lorazepam

(Ativan), clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium)—effective immediately, but addictive

– Antihistamines—hydroxyzine (Vistaril, Atarax), diphenhydramine (Benadryl)

– Antidepressants—trazodone (Desyrel)– Antipsychotics—quetiapine (Seroquel),

thioridazine (Mellaril)

31

Appendix 2: Case Examples of Students on Psychotropic Medications

• History of ADHD with good response to stimulant medications, but seems poorly organized off medications, very forgetful. Does not want to restart medication—considers it a sign of weakness. What would you advise?

• History of depression, on antidepressant medications for 2 years, feeling “normal” and wants to stop medication. How would you advise?

32

Appendix 2: Case Examples of Students on Psychotropic Medications (cont’d)

• History of depression, started medications 3 weeks before arrival, still symptomatic. How would you handle?

• Bipolar Disorder for over 6 years, stabilized for last year, on same meds, but ran out a week ago, went 5 days without, restarted yesterday, but out of control. What would you advise?

33

Appendix 2: Case Examples of Students on Psychotropic Medications (cont’d)

• History of an antipsychotic medication needed for paranoia, but recently stopped 2 weeks ago, and appears fine. How would you advise?

34