1. Medication and Treatment Challenges for the Young Adult
Karen Moeller, PharmD, BCPP Clinical Associate Professor
The University of Kansas
School of Pharmacy
Heidi Wehring, PharmD, BCPP
Assistant Professor
The University of Maryland
School of Medicine
How may people take medications
How many people think they don’t need medications?

2. Medication Challenges
Drugs don’t work in patients who don’t take them.
— C. Everett Koop, M.D

3. Objectives
Review mental illnesses and substance abuse risk in young adults.
Discuss risks and benefits of medications in young adults.
Empower young adults to seek important information about their medications.

4. Adolescence and Young Adulthood
Changes in family relationships
Increased academic load
Increased responsibilities
Job experiences
Driving
In other words, there’s a lot going on!

5. Considerations for Systems of Care
Transition-age youth
between child focused and adult-focused staff
Younger people with severe mental illnesses could be at risk for missing milestones
Early recognition and seeking treatment are important steps
80% of persons with depression improve with treatment
Nordqvist, 2009

6. Costs of Mental Illness- MDE in Young Adults
Depression in young adults is associated with increased risk of:
substance abuse
unemployment
early pregnancy
educational underachievement
Suicide: third leading cause of death in 14- to 24-year-olds
Centers for Disease Control and Prevention, National Center for Injury Prevention and Control, Division of Violence Prevention. Suicide prevention: youth suicide

7. Mental Health and Substance Abuse
Mental illness: more common in late adolescents and young adults than in youth under age 16
Half of all lifetime cases of mental health and substance use disorders occur by age 14
¾ by age 24
If not addressed, mental health issues may
Affect academic and employment achievement
Increase likelihood for justice system involvement
Hinder relationship development
Masi and Cooper, 2006; Kessler et al., 2005

8. Mental Health by the Numbers
In the past year:
1 in 10 teens ages had a major depressive episode
1 in 5 young adults (18-25) had a mental illness
4% of young adults had a serious mental illness
This group generally had poorer quality of life than persons without mental illness
THE CBHSQ Report, May

9. Mental Health: Unmet Needs
Needs are not always met
1 in 10 teens ages had a major depressive episode (MDE)
60% did not receive mental health services
1 in 5 young adults (18-25) had a mental illness
67% did not receive mental health services
4% of young adults had a serious mental illness
47% did not receive treatment
SAMHSA, 2013

10. Why? Young adults are healthy New onset of symptoms
Less regular interaction with physician
New onset of symptoms
Less knowledge that a diagnosable condition
Recognition of need for intervention
Young adults report less use of counseling services among persons with depression
Decision-making
Yu et al., J Adolesc Health 2008

11. Why Not Seek Treatment? Stigma “I couldn’t pay”
“It’s hard to make appointments”
“I don’t know who to see”
“How will talking or taking a pill help?”
According to college students surveyed, stigma still the #1 barrier to seeking help
Yu et al., J Adolesc Health 2008; College Students Speak 2012

12. Co-occurring Illness: Impact on Recovery
Twice as high in young adults vs 26+
19% vs 7%
SUD can increase challenges to persons with another mental health condition
Physical health
Treatment response
Increased risk of legal/familial issues
Being empowered to seek and receive treatment is important in addressing these challenges
Young adults:
higher rates of co-occurring SUD, MI
6/10 persons with SUD also suffer from another MI
Persons with a history of abuse
or other trauma at increased risk
Young adults have higher rates of co-occurring substance use disorder and mental illness than older adults
CBHSQ, Results from the 2012 National Survey on Drug Use and Health

13. The Good News: Effective treatments are available
Non-medication treatment
Medication
Combination of different treatments
Medications are effective in treating the symptoms of many disorders
Young adults may have individual needs and challenges that can be addressed to optimize benefit from treatment

14. What are Medications ? A medicine or drug changes how your body works
Treats or prevents a disease or symptom
Medication can be:
Prescription
Over-the-counter
Herbals
Dietary
Supplements
When used correctly, medicines can lead to:
Better life quality
Healthier life
Longer life

15. Psychiatric Medications How they work
Relieve symptoms
Help prevent return of symptoms
Not one medication is going to work for everybody!!!
Medications Do Not Cure Mental Illness

16. Why do I Need to Take Medications? Benefits of taking my medications
Decrease symptoms
Helps stabilize your mood and thinking
Improves your ability to function during daily activities
Decrease hospitalization and emergency visits
Improves your quality of life
Decrease tension in your personal relationships
Sometimes, it’s hard to know how the medicine will affect you until you try it

17. Medications Take Time to Work
Most psychiatric medicines work gradually before you see the full benefits
Depression – 4-6 weeks
Schizophrenia – weeks to months
Bipolar - weeks
Anxiety – weeks to months
ADHD - immediately

18. Be Part of the Medication Decisions
Get Information
Find out about different types of medications
Talk with others who have similar symptoms
Talk with your doctor about side effects
Sometimes the only way to know if the medication is right for you is to try it!
Ask questions
Request changes if needed
Don’t give

19. KNOW YOUR MEDICATIONS! Questions to ask your health care provider
What is the name of the medication? Is it known by other names? Is there a generic?
What is the medicine for?
How should I take it? Should I take it with food?
When will the medication begin to work?
Why is it important for me to take this?
What are the possible side effects?
Can I take this medication with other medications or vitamins?
Is the medication addictive?
How long do I need to take the medication?

20. Educate before you Medicate

21. Script Yourx Future

22. Prescription Labels

23. Over-the-Counter Labels

24. Side Effects Be aware of side effects and how to handle them
Don’t be afraid of all the side effects listed in the medication leaflet
Just because a side effect is listed in the literature does not mean you will get it
Don’t be afraid to talk with your clinician about side effects
Not talking to your physician about side effects will increase your likelhood of stopping the medication

25. Side Effect Checklist –Less Severe
Symptoms
Possible Solutions to Side Effect
Eyes sensitive to light
Wear sunglasses, hat or visor; Avoid prolong exposure
Dry mouth
Increase water intake; Use hard candies or sugarless gum
Stomach upset
Take medication with meals
Constipation
Increase water intake
Increase physical exercise
Eat green leafy vegetables
Talk with doctor or pharmacist about mild laxatives
Tiredness
Talk to your doctor about switching entire daily dosage at bedtime
Take brief rest periods during the day
Mild restlessness, muscle stiffness
Exercise, take short walks, stretch muscles, relax to music
Weight Gain
Exercise, watch diet and reduce overeating

26. Side Effect Checklist –More Severe Contact your doctor
Blurred vision
Drooling or difficulty swallowing
Tremors (involuntary shaking or tightening of muscles)
Diarrhea for greater than 2 days
Muscle rigidity
Rash
Excessive sedation
Extreme difficulty urinating
Involuntary movements of mouth, tongue, hands or other parts of the body

27. What are Psychotropic Medications?
Antipsychotics
Antidepressants
Mood Stabilizers
Stimulants
Antianxiety/ Hypnotics

28. Antipsychotics Typical Antipsychotics Atypical Antipsychotics
Clozapine (Clozaril®)
Olanzapine (Zyprexa®)*
Risperidone (Risperdal®)*
Paliperidone (Invega®)*
Quetiapine (Seroquel®)
Ziprasidone (Geodon®)
Aripiprazole (Abilify®)*
Asenapine (Saphris®)
Iloperidone (Fanapt®)
Lurasidone (Latuda®)
chlorpromazine (Thorazine®)
thioridazine (Mellaril®)
loxapine (Loxitane®)
molindone (Moban®)
perphenazine (Trilafon®)
trifluoperazine (Stelazine®)
thiothixene (Navane®)
fluphenazine (Prolixin®)*
haloperidol (Haldol®)*
*Available in a Long Acting Injection
(usually take every 2 weeks or monthly)

29. Side Effects of Antipsychotics
Drowsiness
Some are more than other
Usually resolves in a few week
Anticholinergic Side Effects
Dry Mouth
Constipation
Urinary retention
Blurred vision
Increase heart rate
Decreased sweating
Increase Prolactin

30. Side Effects of Antipsychotics
Cardiovascular side effects
May need a EKG
Weight Gain, Diabetes, increase cholesterol
More commonly seen with the atypical antipsychotic.
Make sure you physician is monitoring your weight, blood sugar and cholesterol
Extrapyramidal Side Effects (EPS)
Dystonias
Pseudoparkinsonism
Tardive Dyskinesias
Akathisias
Most Commonly seen with the typical or older agents

31. Common Antidepressants
SSRIs
Prozac® (Fluoxetine)
Zoloft® (Sertraline)
Paxil® (Paroxetine)
Celexa® (Citalopram)
Lexapro® (escitalopram)
Luvox® (Fluvoxamine)
SNRIs
Effexor® (Venlafaxine)
Cymbalta® (Duloxetine)
Pristiq® (Desvenlafaxine)
Others
Wellbutrin® (bupropion)
Remeron® (mirtazapine)
Older Antidepressants (mainly used for sleep or other indications)
Trazodone
Amitriptyline
Doxepin
All Antidepressants have a suicide warning in people <25 years old

32. SSRI and SNRI Side effects
GI – Nausea/Vomiting/Diarrhea
Insomnia
Headache
Nervousness/Jitteriness
Weight Gain/weight loss
Sexual dysfunction
Hypertension (SNRIs only)
Withdrawal reaction
Dizziness, insomnia, anxiety, agitation, nausea, vomiting, sweating, tingling, headache, sensory disturbances
Most Side Effects go away in 2 weeks

33. Others Bupropion (Wellbutrin®) Mirtazapine (Remeron®) Trazodone
Comes in many different dosages forms (Wellbutrin®, Wellbutrin SR®, and Wellbutrin XL®)
Avoid if you have a history of seizures
Also used in smoking cessation and ADHD
Mirtazapine (Remeron®)
Sedation and Weight gain
Often used for sleep
Trazodone
Old antidepressant now used for sleep
Priapism rare side effect

34. Antidepressants and Suicide
All antidepressants have a black box warning for increase risk of suicide in children up to age 24
Greatest risk of suicidal behavior is when a person 1st starts taking an antidepressant (usually around week 2)
Children who develop anxiety, agitation restlessness with AD treatment may be at an increase risk for developing SI
Overall, long term use of AD have been shown to decrease suicide in general population
4% Risk of Suicide with Antidepressants vs. 2% with placebo
Hammad TA.
Kratochvil CJ, et al. J Child Adolesc Psychopharmacol; 2006;16:11-24

35. Mood Stabilizers / Anticonvulsants
Lithium
Valproic Acid (Depakene®, Depakote®, Depakote ER®)
Comes in many dosage forms, make sure you have the correct one prescribed
Carbamazepine (Tegretol®)
Also comes in many different dosage forms
Lamotrigine (Lamictal®, Lamictal ER®)

36. Important Information - Lithium
Don’t get dehydrated!!
Many interaction (Advil, Aleve, Motrin, diuretics)
Narrow Therapeutic index (0.5 – 1.2 meq/L). Easy to reach toxicity

37. Common Side Effects of Mood Stabilizers
Sedation (takes a few days to get use to side effects)
Stomach (usually well tolerated)
Tremor
Less Common but more severe
Call physician if these occur
Decrease platelets (Increased bruising)
Decrease white blood count (frequent infections)
Liver impairment (yellowing of the skin, abdominal pain)
Rash
Drug levels are monitored for most mood stabilizers

38. Psychostimulants
Methylphenidate (Ritalin®, Concerta®, Metadate®, Daytrana®)
Dexmethylphenidate (Focalin®)
Dextroamphetamine (Dexedrine®)
Mixed Amphetamine (Adderall®)
Lisdexamfetamine (Vyvanse®)

39. Adverse Effects - Stimulants
Anorexia/Wt loss
Stomach pain
Insomnia
Rebound Symptoms
Irritability
Depressed Mood
Zombie State
Others
Hypertension
Hallucinations
Tics
Key Points
Talk with your doctor if you have a pre-exsisting heart condition
Anorexia –give high calories meals when stimulants are low (breakfast/evenings)
Stomach pain – administer stimulants after food
Insomnia – administer stimulant as early in the day as possible, discontinue afternnoon or evening doses. Consider adjunctive clonidine or sedating AD
Rebound symp – overlap stimulant dosing, use a second dose of long-acting stimulant
Dysphoria-reduce dose, consider different stimulant, consider comorbid diagnosis
Zombid- reduce dose, change stimulant

40. Benzodiazepines Examples Xanax® (alprazolam) Valium® (diazepam)
Ativan® (lorazepam)
Klonopin® (clonazepam)
Librium® (chlordiazepoxide)
Restoril® (temazepam)

41. Benzodiazepines – Side Effects
Drowsiness
Clumsiness (ataxia)
Fatigue
Confusion
Memory problems
Slowed breathing
ADDICTION
USE CAUTION WHILE DRIVING OR OPERATING HEAVY MACHINERY

42. Hypnotics Non-addicting Risks of Addiction Trazodone
Hydroxyzine
Doxepin
Rozerem (Ramelteon®)
Risks of Addiction
Lunesta® (Eszopiclone)
Sonata® (Zaleplon)
Ambien® (Zolpidem)
Benzodiazepines

43. Abnormal Sleep Behaviors
Warning on all prescription hypnotics
Sleepwalking, sleep driving, sleep eating, etc..

44. Hurdles with Medication
I forget to take my medication
I’m not ill, I don’t need medication
I don’t feel any different, so my medication must not be working
I feel great, so I don’t need my medication anymore
I can’t afford my medication
I don’t want any side effects
Regimen complexity
Dosing frequency greater than twice daily
Remembering doses and refills
Depression
Adverse effects or fearing them
Understanding the regimen
Belief and confidence in therapy
Cost
Ability to read the prescription label

46. Helpful hints to remember to take your medications
Pill Box
Ask your pharmacy if the “bubble pack” / “blister pack” or fill pill boxes

47. Helpful hints to remember to take your medications
Make a Calendar
Set Alarms / Reminders

48. Helpful hints to remember to take your medications
Smart Phone Apps (free)
iPhone and Android
MyMedSchedule
MyMeds
MedSimple
PillManager

49. Helpful hints to remember to take your medications
Make it part of your daily routine
Aways Keep Medication out of the Reach of Children!

50. Other Options Long acting injections are options for certain medicines
Once every 2 to 4 weeks VS taking pills every day
Oral medicines that can be taken once daily may offer benefit over others that need to be taken multiple times a day
If scheduling medicine doses is a challenge, ask your doctor about options!

51. High Cost Medications
Ask your doctor or pharmacist for a cheaper alternative
Let your doctor know you can’t afford a high cost medication
Visit RxAssist or Partnership for Prescription Assistance
Websites for prescription assistance program
Look for medication coupons
Get price quotes
-GoodRx ( offers price comparisons
Ask about medication samples

52. Using Your Medications Safely
Avoid Alcohol and Street drugs while on psychiatric medication
Be up front about what you usually use
Be careful while driving or using machinery
Never stop your medication abruptly
If you miss a dose – Never double up on the medication
If your medication makes you feel sick – talk with your doctor or pharmacist ASAP
If you are thinking about becoming pregnant or breast feeding talk with your doctor or pharmacist
Make sure you doctor knows ALL your medications

53. Dietary Supplements & Herbal Medications
Allows talk with your doctor or pharmacist prior to taking
Many have drug interactions and may worsen your disease
Herbal medications do not follow the same rules that prescription drugs do.
Manufacturers do not have to prove that the product is safe, effective, or that it contains the ingredients on the label.

54. Lasting Thoughts

55. Feeling better is a sign the medication is working
Always talk to your doctor before stopping a medication
Some medications have to be gradually lowered before one can get completely off
Some illness, like schizophrenia, require lifelong treatment.
Treatment durations among individuals

56. Remember it takes time for medications to work
Psychiatric Medications treat symptoms – they do not Cure Mental illness
You still may have some symptoms while on medications
Talk with your doctor if you don’t think it is working

57. Consider a long acting injectable medication if available
REMEMBER
Get a pill box
Set Alarms
Ask your doctor to simply your regimen
Make it part of your routine
Consider a long acting injectable medication if available

58. REMEMBER – BE IN CHARGE OF YOUR MEDICATION
Be sure you have the correct dosage
Find out about different types of medications
Talk with your doctor about side effects
Avoid Medication interaction
Ask questions
Request changes if needed
Don’t give

59. Where do I get more information
NAMI Information on Treatment
NAMI On Campus

60. Summary
Mental illness is common among young adults and may occur with SUD
Developmental and lifestyle challenges contribute to the complexity of seeking and getting the most out of treatment interventions
These illnesses can be addressed and treated
Medications are helpful treatment options for many symptoms
Being empowered to seek information and optimize medication use is an important aspect of the road to recovery