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%

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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

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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

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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)

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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)

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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)

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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)

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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)

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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

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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)

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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.

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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

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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

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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

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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.

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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)

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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

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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

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MONITORING STUDENTS THROUGHOUT THEIR STAY

Part 5

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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

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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

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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

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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

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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

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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%)

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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

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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.

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MEDICATIONS BY CATEGORY

Appendix 1

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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

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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)

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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)

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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)

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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)

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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)

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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)

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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)

04/20/23 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)

04/20/23 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.

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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

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

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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

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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.

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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

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Medications by Category

Antianxiety Agents (ANX)—[continued] Anticonvulsants

Divalproex sodium (Depakote) Gabapentin (Neurontin) Pregablin (Lyrica) Tiagabine (Gabitril)

TCA Antidepressants Clomipramine (Anafranil)

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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)

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