Preparing the Adult Mental Health Workforce to Succeed in a Transformed System of Care

1. 1   Preparing the Adult Mental Health Workforce to Succeed in a Transformed System of Care Psychiatric Medication: Uses, Side Effects, and Practices Module XII NASMHPD/OTA Curriculum Module Created by Huckshorn & Jorgenson November 2008 This module will cover the use of common psychiatric medications. No short training can cover the literally hundreds of medications that you have heard about, or have used in your work in mental health settings. We have chosen to cover the most common medications that are used to help people with serious mental conditions manage their symptoms and to discuss the ways in which we can monitor and manage the side effects of these medications. Every person who works in a mental health setting needs to be knowledgeable about the use of medications, especially what they do, do not do, and their side effects. This module will cover the use of common psychiatric medications. No short training can cover the literally hundreds of medications that you have heard about, or have used in your work in mental health settings. We have chosen to cover the most common medications that are used to help people with serious mental conditions manage their symptoms and to discuss the ways in which we can monitor and manage the side effects of these medications. Every person who works in a mental health setting needs to be knowledgeable about the use of medications, especially what they do, do not do, and their side effects.

2. 2 Objectives Provide a general overview of the history and role of medications used to treat mental health disorders Become familiar with basic medication actions and definitions Understand the need for an individualized approach to prescribing Learn the basics about meds (and side effects) in the treatment of depression, bi-polar disorder, anxiety, and psychotic disorders Understand the primary role of direct care staff Read Objectives and remind audience they are in different roles and jobs and will have different understandings about medications to date and that is fine. Read Objectives and remind audience they are in different roles and jobs and will have different understandings about medications to date and that is fine.

3. 3 Psychiatric Medication:Medication Debated for Years Primarily the debate has been between the use of psychodynamic therapies, behavioral therapies, and biology (using meds) (Preston, O�Neal, & Talaga, 2006) In the middle of the 20th Century, the first psychotropic medications were developed. These seemed to greatly help some people get better, and even get out of the hospitals for the first time, by reducing hallucinations and delusions. At the same time, some professionals had become very hopeful about the positive effects of other kinds of therapies, including one-to-one extended psychotherapy, behavioral therapies, and group interventions. For some period of time (1960�s to 1980�s, primarily) people with serious mental conditions continued to be treated with a combination of therapies, including medications. However, no one regime or medication seemed to work consistently on everyone. In the middle of the 20th Century, the first psychotropic medications were developed. These seemed to greatly help some people get better, and even get out of the hospitals for the first time, by reducing hallucinations and delusions. At the same time, some professionals had become very hopeful about the positive effects of other kinds of therapies, including one-to-one extended psychotherapy, behavioral therapies, and group interventions. For some period of time (1960�s to 1980�s, primarily) people with serious mental conditions continued to be treated with a combination of therapies, including medications. However, no one regime or medication seemed to work consistently on everyone.

4. 4 Psychiatric Medication Approach the use of medications with an understanding that we do not entirely know how these meds work or why The evidence base for the use of mental health medications is still in process� (Preston, O�Neal, & Talaga, 2006) Approach the use of medications for mental health conditions (psychotropics) with the understanding that we do not know exactly how these meds work, or why they work for some and not others, or even why they may work in the beginning and not so well later on. However, researchers continue to study the use of medications, and every year we learn more. There is strong evidence that certain medications work very successfully for certain signs and symptoms, for some individuals. Approach the use of medications for mental health conditions (psychotropics) with the understanding that we do not know exactly how these meds work, or why they work for some and not others, or even why they may work in the beginning and not so well later on. However, researchers continue to study the use of medications, and every year we learn more. There is strong evidence that certain medications work very successfully for certain signs and symptoms, for some individuals.

5. 5 Psychiatric Care: History of Treatment 1800�s�Basic compassionate care Late 1800�s�Biological model: brain pathology (e.g. syphilis, pellagra) 1920�s�Psychological therapies�. Freud 1940�s�Somatic therapies (ECT, wet packs insulin shock, psychosurgery) (Preston, O�Neal, & Talaga, 2006) Mental Health professionals have argued and debated the best way to treat mental illness for decades and longer. Before medications were developed, people were treated by a huge variety of interventions that ranged from: basic compassionate care (safe housing and no treatment [1800�s]); to institutionalization in large walled facilities, working in gardens and basically being kept safe and comfortable; to very intrusive interventions, including insulin-induced coma, cold sheet treatments, and frontal lobotomies. (None of these interventions were based on evidence, rather they were based on �intuition� and hope. And unfortunately, while the people providing these interventions wanted to �help� they often did not, and sometimes they severely hurt of even killed innocent people.) Some therapies that were developed in the 1940�s, such as ECT, or electroconvulsive therapy, are still used today, but their use remains controversial, particularly when applied involuntarily (see Breggin, 2008a). Mental Health professionals have argued and debated the best way to treat mental illness for decades and longer. Before medications were developed, people were treated by a huge variety of interventions that ranged from: basic compassionate care (safe housing and no treatment [1800�s]); to institutionalization in large walled facilities, working in gardens and basically being kept safe and comfortable; to very intrusive interventions, including insulin-induced coma, cold sheet treatments, and frontal lobotomies. (None of these interventions were based on evidence, rather they were based on �intuition� and hope. And unfortunately, while the people providing these interventions wanted to �help� they often did not, and sometimes they severely hurt of even killed innocent people.) Some therapies that were developed in the 1940�s, such as ECT, or electroconvulsive therapy, are still used today, but their use remains controversial, particularly when applied involuntarily (see Breggin, 2008a).

6. 6 Psychiatric Medication:the 1950�s and Three Different Discoveries� Thorazine�.resulted in major decrease in hospital admissions Behaviors and symptoms resulted from brain chemicals and neuro-transmission Genetic Studies (illnesses run in families) (Preston, O�Neal, & Talaga, 2006) In the 1950�s, there were three different discoveries that occurred, not known to each other�. 1. The medication Thorazine was discovered to work well for some symptoms of agitation and psychosis and resulted in a major decrease in hospital admissions� 2. Scientists learned that mental health behaviors and symptoms resulted from brain chemicals and neuro-transmission�and 3. Genetic studies indicated that mental conditions seemed to run in families, and could possibly be inherited like other kinds of medical conditions such as cancer, hypertension, and diabetes. In the 1950�s, there were three different discoveries that occurred, not known to each other�. 1. The medication Thorazine was discovered to work well for some symptoms of agitation and psychosis and resulted in a major decrease in hospital admissions� 2. Scientists learned that mental health behaviors and symptoms resulted from brain chemicals and neuro-transmission�and 3. Genetic studies indicated that mental conditions seemed to run in families, and could possibly be inherited like other kinds of medical conditions such as cancer, hypertension, and diabetes.

7. 7  Psychiatric Medication: Debate Still Continues� Noted Advantages of Medication: Meds can work quickly to decrease symptoms Medication effects have been monitored/studied Medications are typically more available than psychotherapies (Preston, O�Neal, & Talaga, 2006) Read slideRead slide

8. 8 Psychiatric MedicationDebate Still Continues� Noted Disadvantages of Medication: Mental illness is complicated and complex Drugs may interfere with one�s autonomy, free will Psych meds have serious side effects Use of medication can become a �default practice� which is easier than looking at underlying areas of concern Prescribing drugs can give mixed messages to persons with addiction disorders There is a potential for overmedication The pharmaceutical industry engages in aggressive marketing of its products (Preston, O�Neal, & Talaga, 2006; Felitti, 2002; Breggin, 2008b) A number of concerns have been voiced around the use of psychiatric medications: Mental illness is complicated and complex and medication cannot address these issues� Drugs may interfere with a person�s autonomy and free will and can make a person worse� Many psychiatric meds have serious side effects� Meds cannot teach people living skills or how to solve life problems Doctor�s may find it easier to simply prescribe a medication than to delve into complex, underlying problems that the person may have For addicts who �self-medicate� with street drugs to make themselves feel better, it can send a mixed message to offer another kind of drug (i.e. legal) to do the same thing Historically, there has been a trend of over-medicating persons with psychiatric problems. Over-medication can also be a risk for persons seeing multiple providers who may not be aware of other medication (psychotropic or somatic) that the person might be taking. Concerns also exist that aggressive marketing on the part of the pharmaceutical industry has created a demand that does not necessary correspond to real need. There is a spectrum of opinions on this issue. Some advocates take a firm �anti-medication� stance, and oppose the use of any psychiatric medication. Other individuals acknowledge the value of many medications, but simply voice concern over their side effects and possible misuse or overuse. Clearly, the issue is a complex one, and the important point here is to recognize that there are varying viewpoints.A number of concerns have been voiced around the use of psychiatric medications: Mental illness is complicated and complex and medication cannot address these issues� Drugs may interfere with a person�s autonomy and free will and can make a person worse� Many psychiatric meds have serious side effects� Meds cannot teach people living skills or how to solve life problems Doctor�s may find it easier to simply prescribe a medication than to delve into complex, underlying problems that the person may have For addicts who �self-medicate� with street drugs to make themselves feel better, it can send a mixed message to offer another kind of drug (i.e. legal) to do the same thing Historically, there has been a trend of over-medicating persons with psychiatric problems. Over-medication can also be a risk for persons seeing multiple providers who may not be aware of other medication (psychotropic or somatic) that the person might be taking. Concerns also exist that aggressive marketing on the part of the pharmaceutical industry has created a demand that does not necessary correspond to real need. There is a spectrum of opinions on this issue. Some advocates take a firm �anti-medication� stance, and oppose the use of any psychiatric medication. Other individuals acknowledge the value of many medications, but simply voice concern over their side effects and possible misuse or overuse. Clearly, the issue is a complex one, and the important point here is to recognize that there are varying viewpoints.

9. 9 Psychiatric Medication:Public Indoctrination/Belief Unfortunately�there is a belief that if people would just take their medications, all would be fine This is not true It is true that many people can get better using meds, but also that many do not (Preston, O�Neal, & Talaga, 2006) This �lay person� belief that people with mental conditions would be fine if �they just took their medication� is part of the stigma, discrimination, and unfair judgment that surround people with these conditions. We have all been exposed to these �beliefs� but the real truth is much more complicated. This �lay person� belief that people with mental conditions would be fine if �they just took their medication� is part of the stigma, discrimination, and unfair judgment that surround people with these conditions. We have all been exposed to these �beliefs� but the real truth is much more complicated.

10. 10 Psychiatric Medication:2008-We Know the Following A large number of people have been helped Side effects can be quite severe, creating uncomfortable, dangerous, or life-changing problems Psych meds do not cure the illness, but can help some people to better manage their symptoms (Preston, O�Neal, & Talaga, 2006) Studies have shown that medications have helped a large number of people in their recovery process Yet, one fact we should all know if we are going to work in mental health settings is that many of the medications prescribed for serious mental conditions are very powerful and have a lot of very uncomfortable side effects ranging from a hyper-sensitivity to sunlight to rapid, considerable weight gain, and impotence. We also know that some medications greatly help some people to manage their symptoms , though these do not �cure� the mental illness.Studies have shown that medications have helped a large number of people in their recovery process Yet, one fact we should all know if we are going to work in mental health settings is that many of the medications prescribed for serious mental conditions are very powerful and have a lot of very uncomfortable side effects ranging from a hyper-sensitivity to sunlight to rapid, considerable weight gain, and impotence. We also know that some medications greatly help some people to manage their symptoms , though these do not �cure� the mental illness.

11. Ethnopsychopharmacology Impact of ethnicity and culture on response to medication Lower doses of some medications are indicated for certain groups Racial/ethnic variation related to both genetic and psychosocial factors Medication effects interpreted differently by different cultures Possibility of clinician bias in diagnostic and prescribing practices (USDHHS, 1999; Well, 1998) 11 Ethnopsychopharmacology is an area of study that looks at the way in which social, cultural, environmental, and genetic factors can impact the way in which different racial and ethnic groups respond to psychotropic medications. Research in this area has increased significantly over the past two decades. Because the metabolism of many drugs is controlled by enzymes, and because those enzymes may vary across racial and ethnic groups, there may be a need to adjust dosing levels accordingly so as to avoid toxicity. For example, studies have found that Asian consumers with schizophrenia may require significantly lower doses of antipsychotic medications than Caucasians to reach the same blood levels. Diet and the use of herbal remedies can also have an impact on medication effects. It is vital for practitioners to be aware of the impact that cultural factors can have on a person�s views towards illness, recovery, and medication use. Studies have found a pattern of over-diagnosis of schizophrenia for African American males, with accompanying mis-prescribing/over-prescribing of medication. The key here is for providers to be well-informed and aware of possible differences along lines of race and culture and to design treatment accordingly. Ethnopsychopharmacology is an area of study that looks at the way in which social, cultural, environmental, and genetic factors can impact the way in which different racial and ethnic groups respond to psychotropic medications. Research in this area has increased significantly over the past two decades. Because the metabolism of many drugs is controlled by enzymes, and because those enzymes may vary across racial and ethnic groups, there may be a need to adjust dosing levels accordingly so as to avoid toxicity. For example, studies have found that Asian consumers with schizophrenia may require significantly lower doses of antipsychotic medications than Caucasians to reach the same blood levels. Diet and the use of herbal remedies can also have an impact on medication effects. It is vital for practitioners to be aware of the impact that cultural factors can have on a person�s views towards illness, recovery, and medication use. Studies have found a pattern of over-diagnosis of schizophrenia for African American males, with accompanying mis-prescribing/over-prescribing of medication. The key here is for providers to be well-informed and aware of possible differences along lines of race and culture and to design treatment accordingly.

12. Individualized Approach to Prescribing Medication Factors to Consider: Adjustments in dosing for elderly persons Off-label use of medication in youth Medication and pregnancy Cigarette smoking Cognitive limitations Personal needs, responses, and preferences (NIMH, 2002; Desai, Seabolt, & Jann, 2001; Fraser, 1999) 12 In addition to the factors of race, ethnicity, and culture, there are a wide variety of other variables that should be considered when prescribing medication. For example: The ELDERLY: tend to be more sensitive to medications. Even healthy older people eliminate some medications from the body more slowly than younger persons and therefore require a lower or less frequent dosage to maintain an effective blood level of the drug. Also, because older persons may have an increased number of somatic health problems, care should be exercised related to the effects and interactions of their (potentially multiple) medications. Youth: Not all psychotropic medications that are prescribed to youth have been tested on youth and thereby approved by the FDA for use on youth�such prescribing is referred to as �off-label� use of the medication, and caution should be exercised related to possible unknown side effects. Women: Because some medications can cause birth defects, care should be used to ensure that a new female consumer being prescribed such medication is not pregnant. Cigarette smoking: can affect the pharmacokinetic and pharmacodynamic properties of many psychotropic drugs. Clinicians should consider smoking as an important factor in the disposition of these drugs. Cognitive limitations: Persons with cognitive limitations may not be able to accurately communicate existing physical concerns (that could be an underlying cause of a behavior change), or the side effects of a new medication. Care should also be exercised with regard to dosing, as more research is needed on the pharmacokinetic properties of different categories of psychotropic medications in persons with developmental disabilities. The key point here, is that the approach to prescribing medication must always be highly individualized to meet the needs and responses of each individual. In addition to the factors of race, ethnicity, and culture, there are a wide variety of other variables that should be considered when prescribing medication. For example: The ELDERLY: tend to be more sensitive to medications. Even healthy older people eliminate some medications from the body more slowly than younger persons and therefore require a lower or less frequent dosage to maintain an effective blood level of the drug. Also, because older persons may have an increased number of somatic health problems, care should be exercised related to the effects and interactions of their (potentially multiple) medications. Youth: Not all psychotropic medications that are prescribed to youth have been tested on youth and thereby approved by the FDA for use on youth�such prescribing is referred to as �off-label� use of the medication, and caution should be exercised related to possible unknown side effects. Women: Because some medications can cause birth defects, care should be used to ensure that a new female consumer being prescribed such medication is not pregnant. Cigarette smoking: can affect the pharmacokinetic and pharmacodynamic properties of many psychotropic drugs. Clinicians should consider smoking as an important factor in the disposition of these drugs. Cognitive limitations: Persons with cognitive limitations may not be able to accurately communicate existing physical concerns (that could be an underlying cause of a behavior change), or the side effects of a new medication. Care should also be exercised with regard to dosing, as more research is needed on the pharmacokinetic properties of different categories of psychotropic medications in persons with developmental disabilities. The key point here, is that the approach to prescribing medication must always be highly individualized to meet the needs and responses of each individual.

13. 13 Psychiatric Medication:Neuro-Biology It is important to know that: Psychiatric or �neuroleptic� medications work to change the way normal brain chemicals work These medications are different from �drugs of abuse,� in that they do not cause highs or addiction issues from a pure substance abuse stance�But they can be used sometimes in ways that are not approved by the prescribing clinician (Preston, O�Neal, & Talaga, 2006) We are not going to go into the neuro-biology of psychiatric meds in this training module. But it is important to know that psychiatric or �neuroleptic� medications work to change the way normal brain chemicals work [they add to or limit them]. Emphasize that regardless of the names that some use to describe these medications, like major tranquilizers for instance, these medications are not to be confused with drugs used to �get high� like heroin, cocaine or alcohol. We are not going to go into the neuro-biology of psychiatric meds in this training module. But it is important to know that psychiatric or �neuroleptic� medications work to change the way normal brain chemicals work [they add to or limit them]. Emphasize that regardless of the names that some use to describe these medications, like major tranquilizers for instance, these medications are not to be confused with drugs used to �get high� like heroin, cocaine or alcohol.

14. 14 Psychiatric Medication: Definition Drug: Any substance that brings about a change in biological function through chemical actions Absorbed through stomach, small intestine, brain Distributed and deposited in organs and tissues Excreted through many routes�kidneys, GI tract, sweat, saliva These factors relate to how fast a drug works and for how long (Preston, O�Neal, & Talaga, 2006) Drugs are absorbed mostly through the stomach or small intestine; the final site being the brain Drugs are distributed in many ways and deposited in different organs and tissues Drugs are excreted through many routes, including the kidneys, GI tract, sweat, saliva These factors relate to how fast a drug work and for how longDrugs are absorbed mostly through the stomach or small intestine; the final site being the brain Drugs are distributed in many ways and deposited in different organs and tissues Drugs are excreted through many routes, including the kidneys, GI tract, sweat, saliva These factors relate to how fast a drug work and for how long

15. 15 Psychiatric Medication: Primary Effects Medications have five (5) primary effects: The desired effect Side effects Idiosyncratic effects (unwanted and unexpected) Allergic effects Withdrawal effects (Preston, O�Neal, & Talaga, 2006) Review the five primary effects of medication. Note that these effects apply to any medication, not just psychotropics.Review the five primary effects of medication. Note that these effects apply to any medication, not just psychotropics.

16. 16 Depressive [Mood] Disorders:Broad Group-Common Symptoms Affective or mood disorders Situational Depression Clinical Depressions major unipolar bipolar minor (dysthymias) (Preston, O�Neal, & Talaga, 2006) The vast majority of persons experiencing reactive sadness or grief (Situational Depression) do not need professional help, as these issues resolve in time. Make clear to the audience the difference between simple and situational depression, and those types of clinical depressions that may require ongoing treatment.The vast majority of persons experiencing reactive sadness or grief (Situational Depression) do not need professional help, as these issues resolve in time. Make clear to the audience the difference between simple and situational depression, and those types of clinical depressions that may require ongoing treatment.

17. 17 Depressive [Mood] Disorders Certain medical disorders can cause depressions �need to be ruled out before a diagnosis is made as medical interventions can resolve what appears as a depressed state. Alcohol and medical use drugs can cause chemical depression When clinical depression is diagnosed, the good news is that medication is often very effective (with the right med, right dose) The most serious depressions present with psychotic symptoms (Preston, O�Neal, & Talaga, 2006) Read slide. Also note that for people who are abusing alcohol or any other drugs, it is impossible to make a good diagnosis while they are still using, and they need to be detoxed or stop using the drug of abuse for some period of time for a diagnosis to be clear. This, of course, is problematic in our current system of short stays. Also, some clinical depression can cause serve mood disturbances, but not psychosis. Other clinical depressions can end up with psychotic symptoms that may require treatment with both an antidepressant and an anti-psychotic. Read slide. Also note that for people who are abusing alcohol or any other drugs, it is impossible to make a good diagnosis while they are still using, and they need to be detoxed or stop using the drug of abuse for some period of time for a diagnosis to be clear. This, of course, is problematic in our current system of short stays. Also, some clinical depression can cause serve mood disturbances, but not psychosis. Other clinical depressions can end up with psychotic symptoms that may require treatment with both an antidepressant and an anti-psychotic.

18. 18 Depressive Disorders Medications Older antidepressants: Including MAOI�s & Tricyclics (Parnate, Nardil) Side effects are quite serious� sedation, hypertension, hypotension, and anticholinergic effects (Preston, O�Neal, & Talaga, 2006) Older Anti-depressants, including MAOI�s (monoamine oxidase inhibitors) and Tricyclics (such as Parnate and Nardil) had side effects that are quite serious in terms of sedation, hypertension, hypotension, and anticholinergic effects (dry mouth, dry skin, blurred vision, constipation, paralyticileus)� Most people being medicated for depression today are now on SSRI�s (Selective Seratonin Reuptake Inhibitors) the newer type of antidepressant drugs, that have fewer side effects. Note, though, that the people that are stable on Tricyclics may still take these. Older Anti-depressants, including MAOI�s (monoamine oxidase inhibitors) and Tricyclics (such as Parnate and Nardil) had side effects that are quite serious in terms of sedation, hypertension, hypotension, and anticholinergic effects (dry mouth, dry skin, blurred vision, constipation, paralyticileus)� Most people being medicated for depression today are now on SSRI�s (Selective Seratonin Reuptake Inhibitors) the newer type of antidepressant drugs, that have fewer side effects. Note, though, that the people that are stable on Tricyclics may still take these.

19. 19 Depressive DisordersMedications Newer types of antidepressant drugs: SSRI�s: Prozac, Celexa, Lexapro, Luvox, Paxil, Zoloft SNRI�s: Effexor, Cymbalta, Remeron NRI�s: Strattera Atypical: Wellbutrin, Serzone, BuSpar (Preston, O�Neal, & Talaga, 2006) All these drugs take up to 28 days to work � They block certain brain chemicals to work� They have a variety of side effects (but these are less severe than those of the older medications�So the newer medications are generally considered �better� due to less side effects and improved safety.) FYI for Presenter: SSRI=Selective serotonin reuptake inhibitors SNRI=Serotonin-norepinephrine reuptake inhibitor. NRI=Natural Reuptake Inhibitor All these drugs take up to 28 days to work � They block certain brain chemicals to work� They have a variety of side effects (but these are less severe than those of the older medications�So the newer medications are generally considered �better� due to less side effects and improved safety.) FYI for Presenter: SSRI=Selective serotonin reuptake inhibitors SNRI=Serotonin-norepinephrine reuptake inhibitor. NRI=Natural Reuptake Inhibitor

20. 20 Bi-Polar Disorder Medications Lithium (LiCO3) requires close monitoring. Blood levels�monitored Watch for tremors, confusion, slurred speech, stupor are serious warning signs of toxicity (Preston, O�Neal, & Talaga, 2006) Lithium is the oldest and most traditional treatment. It has a narrow therapeutic window � Effects occur in 5-14 days� Emphasize the significant and dangerous side effects of LICO2 and how they manifest. Emphasize that any symptoms or signs of new tremors, confusion, slurred speech, or stupor require immediate attention and physician notification. In the meantime, it is safer to �hold� the dose of medication ordered. All nurses can use their judgment to make these kinds of decisions in the field. Also note that many people with bi-polar disorder kind of �like the high of hypo-mania� and do not like the �down� (including side effects of the gastro intestinal system, central nervous system, and kidneys, as well as skin disorders and weight gain) that comes from taking LICO3. Often this is because their dosage level may be too high. At other times the psychiatrist, psychologists, social workers, and nurses must take time to work with the person on understanding that they have an illness and need treatment if they are to avoid constant hospitalizations and other untoward problems.Lithium is the oldest and most traditional treatment. It has a narrow therapeutic window � Effects occur in 5-14 days� Emphasize the significant and dangerous side effects of LICO2 and how they manifest. Emphasize that any symptoms or signs of new tremors, confusion, slurred speech, or stupor require immediate attention and physician notification. In the meantime, it is safer to �hold� the dose of medication ordered. All nurses can use their judgment to make these kinds of decisions in the field. Also note that many people with bi-polar disorder kind of �like the high of hypo-mania� and do not like the �down� (including side effects of the gastro intestinal system, central nervous system, and kidneys, as well as skin disorders and weight gain) that comes from taking LICO3. Often this is because their dosage level may be too high. At other times the psychiatrist, psychologists, social workers, and nurses must take time to work with the person on understanding that they have an illness and need treatment if they are to avoid constant hospitalizations and other untoward problems.

21. 21 Bi-Polar DisorderMedications Other drugs used for Bi-polar disorders: Tegretol, Depakote, and Lamictal Some require blood level monitoring Watch for rashes and report any signs (Preston, O�Neal, & Talaga, 2006) Other drugs used for Bi-polar disorders include Tegretol, Depakote, and Lamictal� These drugs are generally used for seizure disorders but have been effective here� Some require blood level monitoring� Watch for rashes and report any signs� ++ Also note that the atypical anti-depressants are sometimes used for these disorders to good effect Other drugs used for Bi-polar disorders include Tegretol, Depakote, and Lamictal� These drugs are generally used for seizure disorders but have been effective here� Some require blood level monitoring� Watch for rashes and report any signs� ++ Also note that the atypical anti-depressants are sometimes used for these disorders to good effect

22. 22 Anxiety Disorders: Medications Primary anxiety Anxiety caused by other illnesses or issues A very thorough diagnosis is required for these, as symptoms can mimic each other or be complicated Anxiety, often coupled with insomnia, is quite common, and medications have been overused or mis-used by some (Preston, O�Neal, & Talaga, 2006) Now we will switch to anxiety disorders. These include a complex list of primary anxiety and anxiety caused by other illnesses or issues� A very thorough diagnosis is required for these and all mental health disorders as symptoms can mimic each other or be complicated. Emphasize how common anxiety disorders are, and that they range on a continuum from mild and situationally-triggered anxiety, to full blown panic and serious phobias that interfere with daily functioning.Now we will switch to anxiety disorders. These include a complex list of primary anxiety and anxiety caused by other illnesses or issues� A very thorough diagnosis is required for these and all mental health disorders as symptoms can mimic each other or be complicated. Emphasize how common anxiety disorders are, and that they range on a continuum from mild and situationally-triggered anxiety, to full blown panic and serious phobias that interfere with daily functioning.

23. 23 Anxiety Disorders Medications Benzodiazepines: Valium, Librium, Ativan, Xanax, and many others These meds have abuse potential Constant use builds tolerance This can lead to dependency Education is essential (Preston, O�Neal, & Talaga, 2006) -For true anxiety D.O. the most common medications used to treat these acute and uncomfortable symptoms are the �benzodiazepines�. You will be familiar with some of these drugs -These include Valium, Librium, Ativan, Xanax, and many others. -These meds have abuse potential and constant use builds tolerance, which can lead to dependency. -So, doses may need to be increased over time. Dosage should be monitored. -Note that �benzodiazepine dependency� also can lead to a serious withdrawal syndrome that must be treated in the general medical facility in most cases and with IV drugs. -For true anxiety D.O. the most common medications used to treat these acute and uncomfortable symptoms are the �benzodiazepines�. You will be familiar with some of these drugs -These include Valium, Librium, Ativan, Xanax, and many others. -These meds have abuse potential and constant use builds tolerance, which can lead to dependency. -So, doses may need to be increased over time. Dosage should be monitored. -Note that �benzodiazepine dependency� also can lead to a serious withdrawal syndrome that must be treated in the general medical facility in most cases and with IV drugs.

24. 24 Anxiety DisordersMedications We are getting better in fine-tuning the choices of medication for anxiety and insomnia Some meds are long acting and some just cause sedation but not tolerance Some of these drugs cause a withdrawal effect (Preston, O�Neal, & Talaga, 2006) We are getting better in fine-tuning the choice of medication for anxiety and insomnia Depending on the type of anxiety and the triggers for that we now have medications that are very short acting for acute anxiety (fear of flying for example) and for insomnia that only last thru the night and do not affect daytime functioning, like Ambien. Some meds are long acting and some just cause sedation but not tolerance (Vistaril) We are getting better in fine-tuning the choice of medication for anxiety and insomnia Depending on the type of anxiety and the triggers for that we now have medications that are very short acting for acute anxiety (fear of flying for example) and for insomnia that only last thru the night and do not affect daytime functioning, like Ambien. Some meds are long acting and some just cause sedation but not tolerance (Vistaril)

25. 25 Anxiety Disorders Medications Patients on these meds need to understand the reasons and be cautioned about the risks People with anxiety disorders should also be educated in other ways to manage their anxiety (Preston, O�Neal, & Talaga, 2006) -Patients on these meds need to understand the reason and cautioned about the risk of dependency, combining these drugs with other drugs inc. alcohol, and any impairment of coordination -Some of these drugs cause a withdrawal effect -People with anxiety disorders should also be educated in other ways to manage their anxiety and to avoid depending on medication only Emphasize that people being treated with any of these meds need really good education on their use and misuse as well as monitoring over time. -Patients on these meds need to understand the reason and cautioned about the risk of dependency, combining these drugs with other drugs inc. alcohol, and any impairment of coordination -Some of these drugs cause a withdrawal effect -People with anxiety disorders should also be educated in other ways to manage their anxiety and to avoid depending on medication only Emphasize that people being treated with any of these meds need really good education on their use and misuse as well as monitoring over time.

26. 26 Psychotic Disorders Medications The very first anti-psychotic discovered was Thorazine, in 1952, used for post-op sedation The next meds discovered were the �phenothiazines� For a long time, we did not know how they worked (Preston, O�Neal, & Talaga, 2006) In some ways anti-psychotic medications have revolutionized the treatment of psychosis, but in other ways they have greatly slowed other effective treatments that take more time, skills, and money by providers In some ways anti-psychotic medications have revolutionized the treatment of psychosis, but in other ways they have greatly slowed other effective treatments that take more time, skills, and money by providers

27. 27 Psychotic Disorders Medications The �Phenothiazines� - the typical antipsychotics/first generation�OLD Atypical antipsychotic drugs/second generation�NEW The newest research (the CATIE study of OLD and NEW) effectiveness similar�different in side effects (Preston, O�Neal, & Talaga, 2006) We will cover the phenothiazines (also known as the typical antipsychotics/first generation) and the A-typical antipsychotic drugs/second generation These are two very different classes of drugs and are also known as �old� and �new� The newest research (the CATIE study) now demonstrates that these two types of meds are similar in effectiveness However, these two groups (typical and A- (non) typical have very different side effects (profiles) FYI for Presenter: The CATIE Study refers to the Clinical Antipsychotic Trials of Intervention Effectiveness, a wide scale study with funding from NIH.We will cover the phenothiazines (also known as the typical antipsychotics/first generation) and the A-typical antipsychotic drugs/second generation These are two very different classes of drugs and are also known as �old� and �new� The newest research (the CATIE study) now demonstrates that these two types of meds are similar in effectiveness However, these two groups (typical and A- (non) typical have very different side effects (profiles) FYI for Presenter: The CATIE Study refers to the Clinical Antipsychotic Trials of Intervention Effectiveness, a wide scale study with funding from NIH.

28. 28 Psychotic Disorders Medications-SIDE EFFECT PROFILES What this means is that a person who has a psychotic disorder could be treated by medications from either of these drug groups successfully for the psychotic symptoms But the SIDE EFFECTS MAY BE UNBEARABLE for that person and they may stop using the meds because of them Take care not to affix the label of �non-compliant� to persons who choose to cease the use of medication due to side effects (Preston, O�Neal, & Talaga, 2006; Breggin, 2008b) This issue of �side effects� (called side effect profiles) is very important for you to understand� What this means is that a person who has a psychotic disorder could be treated by medications from either of these drug groups successfully FOR THE PSYCHOTIC SYMPTOMS�. But the side effects may be unbearable for that person and they may stop using the med because of the side effects� Note that WE need to avoid blaming people for stopping their medications!!! Avoid use of the term� non-compliant� for persons who express a desire to stop taking a medication due to its side effects. Here, ask the audience to think of whether or not they or a loved one has ever stopped taking any medication (for example, an antibiotic) before they were finished with the full course of treatment because they did not like the side effects. Mention, too, that those medications probably had far fewer and less intense side effects than the antipsychotic medications that the consumers in their system are takingThis issue of �side effects� (called side effect profiles) is very important for you to understand� What this means is that a person who has a psychotic disorder could be treated by medications from either of these drug groups successfully FOR THE PSYCHOTIC SYMPTOMS�. But the side effects may be unbearable for that person and they may stop using the med because of the side effects� Note that WE need to avoid blaming people for stopping their medications!!! Avoid use of the term� non-compliant� for persons who express a desire to stop taking a medication due to its side effects. Here, ask the audience to think of whether or not they or a loved one has ever stopped taking any medication (for example, an antibiotic) before they were finished with the full course of treatment because they did not like the side effects. Mention, too, that those medications probably had far fewer and less intense side effects than the antipsychotic medications that the consumers in their system are taking

29. 29 Psychotic Disorders MedicationsSIDE EFFECT PROFILES Choice between two equally effective groups of meds that have very different side effects Find the medication with the most tolerable side effects for each individual (Preston, O�Neal, & Talaga, 2006) As such, the most important information here is that we have to choose between two equally effective groups of meds that have very different side effects. One physician recently noted that �it means you pick your poison�� in other words you try and find the medication with the most tolerable side effects FOR EACH INDIVIDUAL So, what you need to know about are the different side effect profiles for each of these groups� As such, the most important information here is that we have to choose between two equally effective groups of meds that have very different side effects. One physician recently noted that �it means you pick your poison�� in other words you try and find the medication with the most tolerable side effects FOR EACH INDIVIDUAL So, what you need to know about are the different side effect profiles for each of these groups�

30. 30 Typical Antipsychotic Meds (sometimes called older) Thorazine, Mellaril, Stelazine, Haldol, Prolixin, etc. �also called �neuroleptics� Side Effects include: EPS symptoms, such as slowed movements, decreased facial expression, tremors, shuffling gait, muscle spasms, restlessness, rigidity, tardive dyskinesia; as well as dry mouth, blurred vision, constipation, difficult urination, hypotension, weight gain, and neuroleptic malignant syndrome (Preston, O�Neal, & Talaga, 2006) Read slide. FYI for Presenter: EPS refers to the Extrapyramidal System (the neural network that is part of the brain�s motor system), and EPS symptoms include a range of motor and movement impairments. Tardive dyskinesia: �is a neurological syndrome caused by the long-term use of neuroleptic drugs. Neuroleptic drugs are generally prescribed for psychiatric disorders, as well as for some gastrointestinal and neurological disorders. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also occur. Involuntary movements of the fingers may appear as though the patient is playing an invisible guitar or piano.� [Taken from NIH fact sheet at http://www.ninds.nih.gov/disorders/tardive/tardive.htm ] Neuroleptic malignant syndrome: �is a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. Symptoms include high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunction. In most cases, the disorder develops within the first 2 weeks of treatment with the drug; however, the disorder may develop any time during the therapy period. The syndrome can also occur in people taking anti-Parkinsonism drugs known as dopaminergics if those drugs are discontinued abruptly.� [Taken from NIH fact sheet at http://www.ninds.nih.gov/disorders/neuroleptic_syndrome/neuroleptic_syndrome.htm ] Read slide. FYI for Presenter: EPS refers to the Extrapyramidal System (the neural network that is part of the brain�s motor system), and EPS symptoms include a range of motor and movement impairments. Tardive dyskinesia: �is a neurological syndrome caused by the long-term use of neuroleptic drugs. Neuroleptic drugs are generally prescribed for psychiatric disorders, as well as for some gastrointestinal and neurological disorders. Tardive dyskinesia is characterized by repetitive, involuntary, purposeless movements. Features of the disorder may include grimacing, tongue protrusion, lip smacking, puckering and pursing, and rapid eye blinking. Rapid movements of the arms, legs, and trunk may also occur. Involuntary movements of the fingers may appear as though the patient is playing an invisible guitar or piano.� [Taken from NIH fact sheet at http://www.ninds.nih.gov/disorders/tardive/tardive.htm ] Neuroleptic malignant syndrome: �is a life-threatening, neurological disorder most often caused by an adverse reaction to neuroleptic or antipsychotic drugs. Symptoms include high fever, sweating, unstable blood pressure, stupor, muscular rigidity, and autonomic dysfunction. In most cases, the disorder develops within the first 2 weeks of treatment with the drug; however, the disorder may develop any time during the therapy period. The syndrome can also occur in people taking anti-Parkinsonism drugs known as dopaminergics if those drugs are discontinued abruptly.� [Taken from NIH fact sheet at http://www.ninds.nih.gov/disorders/neuroleptic_syndrome/neuroleptic_syndrome.htm ]

31. 31 Typical Antipsychotic Meds (sometimes called older) Many of these symptoms can be managed Some cannot be managed well enough to keep the person on the medication Dangerous Side Effects� extrapyramidal symptoms tardive dsykenisia, neuroleptic malignant syndrome, metablic disorders If you see these side effects, report them immediately Many of these symptoms can be managed by changing meds, reducing dose, or using other meds like Cogentin. Cogentin and other drugs (Symmetrel, Artane, and Akineton) are used to treat extrapyramidal system (EPS) side effects that are caused by an action of the older antipsychotics that blocks the brain dopamine receptors. In effect, in some people, the older antipsychotics cause a chemically induced �Parkinson�s syndrome�. Specifically these side effects, known as EPS, include slowed movements, decreased facial expressions, tremors, a shuffling gait, muscle spasms or the neck, shoulder and even eyes (can be quite frightening) and intense feeling of restlessness. Please also note that the above EPS symptoms are often confused with symptoms of the mental illness but should not be so confused as EPS is treatable and in some cases is a medical emergency.Many of these symptoms can be managed by changing meds, reducing dose, or using other meds like Cogentin. Cogentin and other drugs (Symmetrel, Artane, and Akineton) are used to treat extrapyramidal system (EPS) side effects that are caused by an action of the older antipsychotics that blocks the brain dopamine receptors. In effect, in some people, the older antipsychotics cause a chemically induced �Parkinson�s syndrome�. Specifically these side effects, known as EPS, include slowed movements, decreased facial expressions, tremors, a shuffling gait, muscle spasms or the neck, shoulder and even eyes (can be quite frightening) and intense feeling of restlessness. Please also note that the above EPS symptoms are often confused with symptoms of the mental illness but should not be so confused as EPS is treatable and in some cases is a medical emergency.

32. 32 Atypical Anti-psychotic meds (sometimes called newer) 1980�s- A new class of atypical meds - Clozaril, Clozapine was the first. Believed to be a great answer to psychosis However, Clozaril causes a blood disorder People on Clozaril require weekly blood tests (Preston, O�Neal, & Talaga, 2006) First believed to be a great answer to psychosis due to the fact that it did not cause EPS (muscle rigidity, slowed motor FX, shuffling) or Tardive Dyskinesia However, clozaril causes a blood disorder ..reduce the white blood cell count �which could cause death from infection as well as a seizure risk. Also note that the CATIE study still found that Clozaril was the most efficacious of all the newer antipsychotics even with the necessity for weekly blood tests. The latter procedure and the problems it causes for the patient is one of the reasons that clozaril is not prescribed as often as it perhaps should be. First believed to be a great answer to psychosis due to the fact that it did not cause EPS (muscle rigidity, slowed motor FX, shuffling) or Tardive Dyskinesia However, clozaril causes a blood disorder ..reduce the white blood cell count �which could cause death from infection as well as a seizure risk. Also note that the CATIE study still found that Clozaril was the most efficacious of all the newer antipsychotics even with the necessity for weekly blood tests. The latter procedure and the problems it causes for the patient is one of the reasons that clozaril is not prescribed as often as it perhaps should be.

33. 33 A-typical Anti-psychotic meds (sometimes called newer) 1980�s Other meds w/o these Side Effects Risperdal, Seroquel, Abilify, Zyprexa, Geodon They do not cause tardive dsykenisia as much They reduce �negative symptoms� However, they also can cause significant weight gain, diabetes, and hyperlipidemia (Preston, O�Neal, & Talaga, 2006) Since the release of Clozaril, other meds have been developed in this family, w/o the Side Effects of the older anti-psychotics. Again, Clozaril is currently believed the most effective and should be tried even with the need for routine blood draws. And again, all of these medications cause significant side effects, some that have great impact on physical health such as diabetes. (see Health Risks Module). [Note: hyperlipidemia refers to an elevation of lipids in the bloodstream which can increase hardening of the arteries.]Since the release of Clozaril, other meds have been developed in this family, w/o the Side Effects of the older anti-psychotics. Again, Clozaril is currently believed the most effective and should be tried even with the need for routine blood draws. And again, all of these medications cause significant side effects, some that have great impact on physical health such as diabetes. (see Health Risks Module). [Note: hyperlipidemia refers to an elevation of lipids in the bloodstream which can increase hardening of the arteries.]

34. 34 Medications for Psychotic Disorders Do not have medications that do not come with serious side effects for psychotic disorders The medication chosen �prescribed based on that individual patient�s symptoms, life, needs, wishes, and ability to manage the side effects People need education and encouragement (Preston, O�Neal, & Talaga, 2006) As you can see, we still do not have medications that do not come with serious side effects for psychotic disorders The medication chosen must be prescribed based on that individual patient�s symptoms, life, needs, wishes, and ability to manage the Side Effects People on these medications need a great deal of education and encouragement to stay on them (as you can now understand�) As you can see, we still do not have medications that do not come with serious side effects for psychotic disorders The medication chosen must be prescribed based on that individual patient�s symptoms, life, needs, wishes, and ability to manage the Side Effects People on these medications need a great deal of education and encouragement to stay on them (as you can now understand�)

35. 35 Medications for Psychotic DisordersConclusions Based on Recent Research Clozapine is the gold standard for treatment resistant schizophrenia Doses are very important to manage side effects It is very hard to predict what med will work best for any one person Responses to meds are very individualized -There are no real differences between old and new anti-psychotic meds except Clozapine. -Switching anti-psychotics is risky. -The newer Antipsychotic drugs are most expensive, have a higher risk of causing metabolic disorders, including diabetes and obesity, and are easier to use w/o motor effects -Older drugs are safe when used a low dose and do not cause metabolic disorders to the same degree -There are no real differences between old and new anti-psychotic meds except Clozapine. -Switching anti-psychotics is risky. -The newer Antipsychotic drugs are most expensive, have a higher risk of causing metabolic disorders, including diabetes and obesity, and are easier to use w/o motor effects -Older drugs are safe when used a low dose and do not cause metabolic disorders to the same degree

36. 36 Final Comments Psychiatric medications are not the �answer� by themselves Medications should be considered ONE TOOL in our �toolbox� They all cause serious and often debilitating side effects Sometimes make people think they are worse Psychiatric medications are not the �answer� to mental health disorders by themselves They all cause serious and often debilitating side effects and sometimes make people think they are worse Medications should be considered ONE TOOL in our �toolbox� and we should be providing many others; rehabilitation, education, hope to get better, exercise, socialization, skill training, family or caregiver involvement, etc. It is very hard to predict what med will work best for any one person Psychiatric medications are not the �answer� to mental health disorders by themselves They all cause serious and often debilitating side effects and sometimes make people think they are worse Medications should be considered ONE TOOL in our �toolbox� and we should be providing many others; rehabilitation, education, hope to get better, exercise, socialization, skill training, family or caregiver involvement, etc. It is very hard to predict what med will work best for any one person

37. 37 Final Comments: Your Role To watch for behavior changes that could be due to medication side effects To listen to �what the people you are serving are saying� about these side effects To take this information seriously/be supportive To watch for serious side effects, and report immediately To ask questions if you have them! Your role is to watch for behavior changes that could be due to medication side effects To listen to �what the people you are serving are saying� about these side effects and take this information seriously/be supportive To watch for serious side effects, esp. flu symptoms, severe rigidity, confusion, severe sedation, large weight gain, excessive thirst, and immediately report this to the senior nurse or your supervisor And to ask questions if you have them! Your role is to watch for behavior changes that could be due to medication side effects To listen to �what the people you are serving are saying� about these side effects and take this information seriously/be supportive To watch for serious side effects, esp. flu symptoms, severe rigidity, confusion, severe sedation, large weight gain, excessive thirst, and immediately report this to the senior nurse or your supervisor And to ask questions if you have them!