1. www.SBCounty.gov Behavioral Health Medical Services California Criminal Justice Reform: Recidivism Reduction Training Psychotropic Medication in Treatment Courts Teresa Frausto, M.D. Chief Medical Officer April 13, 2016

2. www.SBCounty.gov Page 2 Behavioral Health  No conflict of interest. Disclaimer

3. www.SBCounty.gov Page 3 Behavioral Health  History of the mentally ill in corrections.  Review common diagnosis and medication treatments.  Discuss treatment challenges. Goals of Presentation

4. www.SBCounty.gov Page 4 Behavioral Health Origins of the Community Mental Health System  Deinstitutionalization of the severely mentally ill led to the trans institutionalization to the jails and prisons.  Funding from the cost savings achieved through the closures of the state hospitals to the community mental health system did not occur.  Unlike services to persons with developmental disabilities, the mental health system was never conceived as an “entitlement.”  Mental health services were to be provided “to the extent resources are available.”

5. www.SBCounty.gov Page 5 Behavioral Health  Although deinstitutionalization was well intentioned, the failure to provide treatment needs to the severely mentally ill has turned this policy into one of the greatest social disasters of the 20 th century. Origins of the Community Mental Health System

6. www.SBCounty.gov Page 6 Behavioral Health  Release of lower level offenders from the prisons back into the community.  Establishment of the Day Reporting Centers.  Change in the population of the jails with more acute and chronic medical and mental health problems. Assembly Bill 109

7. www.SBCounty.gov Page 7 Behavioral Health  Most Commonly Used Antipsychotics; Antidepressants; Antianxiety (Anxiolytic); Mood Stabilizers; Psychostimulants; and Others. Psychotropic Medications

8. www.SBCounty.gov Page 8 Behavioral Health  Indications Psychotic symptoms  Schizophrenia, Schizoaffective  Psychotic Symptoms Other applications  Delirium/dementia  Substance induced psychosis/agitation  Severe aggression and violence behaviors  Severe Personality disorder Antipsychotics - Indications

9. www.SBCounty.gov Page 9 Behavioral Health  Psychotic Symptoms Positive symptoms  Hallucinations, delusion, disorganization, Agitation Negative symptoms  Alogia (speech), Avolition (drive), Anhedonia (pleasure), Apathy (flat affect) Antipsychotics - Treatment of Symptoms

10. www.SBCounty.gov Page 10 Behavioral Health  Atypical Antipsychotics Clozapine (Clozaril) Risperidone (Risperdal) >>> (Risperdal Consta) Olanzapine (Zyprexa, Zydis)>> (Zyprexa Relprev)* Quetiapine (Seroquel, Seroquel XR) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega) >>> (Invega Sustenna)* Iloperidone (Fanapt)* Asenapine (Saphris)* Lurasidone (Latuda)* Antipsychotic - Medications * Newer AP & Long Acting injectable AP

11. www.SBCounty.gov Page 11 Behavioral Health  Sedation, weight gain and cognitive dulling  Extrapyramidal symptoms (EPS)  Diabetes, Hypertension, increases in Cholesterol  Cardiac changes – for example arrhythmias Antipsychotic - Adverse Reactions

12. www.SBCounty.gov Page 12 Behavioral Health Antidepressant - Indications  Indicators Depressive Disorders  Major Depression  Dysthymia, Depression not otherwise specified Anxiety Disorders  Panic disorders, Social Phobia  Post-traumatic Stress Disorder (PTSD) Other applications  Eating disorders, Obsessive Compulsive Disorder  Premenstrual Dysphoric Disorder  Migraine, pain disorders, impulse control disorders

13. www.SBCounty.gov Page 13 Behavioral Health  Depressive Symptoms Pervasive depressed mood, Excessive guilt feelings, hopeless & helplessness Psychomotor agitation or retardation Severe sleep disturbances Anhedonia, poor concentration Preoccupation with physical health Delusional / Suicide thoughts Antidepressant - Treatment of Symptoms

14. www.SBCounty.gov Page 14 Behavioral Health  Traditional Antidepressants* Monoamineoxidase Inhibitors(MAOI)  Phenelzine (Nardil)  Tranylcypromine (Parnate) Tricyclic Antidepressants (TCAs)  Amitryptyline (Elavil)  Imipramine (Tofranil)  Doxepin (Sinequan)  Clomipramine (Anafranil)** Antidepressant - Medications * Able to measure therapeutic drug level ** Mainly for OCD

15. www.SBCounty.gov Page 15 Behavioral Health  Traditional Antidepressants (continued) Nortryptyline (Pamelor) Desipramine (Norpramin) Protryptyline (Vivactil) Trimipramine (Surmontil) Amoxapine (Arsendin) Antidepressant – Medications (continued)

16. www.SBCounty.gov Page 16 Behavioral Health  Newer Antidepressants Serotinin reuptake inhibitors (SSRIs)  Fluoxetine (Prozac)  Paroxetine (Paxil, Paxil-CR)  Sertraline (Zoloft)  Citalopram (Celexa)  Escitalopram (Lexapro)  Fluvoxamine (Luvox / Luvox CR)*  Vortioxetine (Brintellix) Antidepressant – Medications (continued) * Primarily for OCD

17. www.SBCounty.gov Page 17 Behavioral Health  Newer Antidepressants (continued) Serotonin-Norepinephrine reuptake inhibitors  Venlafaxine (Effexor, Effexor XR)  Duloxetine (Cymbalta)  Desvenlafaxine (Pristiq)  Levomilnacipran (Fetzima) Antidepressant – Medications (continued)

18. www.SBCounty.gov Page 18 Behavioral Health  Other Atypical Antidepressants Mirtazapine (Remeron) Bupropion (Welbutrin, Welbutrin SR, Wellbutrin XL) Trazodone (Desyrel) Vilazodone (Viibryd) Vortioxetine (Brintellix) Antidepressant – Medications (continued)

19. www.SBCounty.gov Page 19 Behavioral Health  Orthostatic Hypotension  Dizziness, Tachycardia  Sedations, Weight gain  Hypertensive Crisis  Dry mouth, blurred vision, constipation  Conduction disturbances  Seizures  Tremors, Ataxia, Delirium (toxic level)  Erectile & ejaculatory dysfunctions Antidepressant - Adverse Reactions

20. www.SBCounty.gov Page 20 Behavioral Health  Anxiety Disorders Panic Disorder, Phobias including Social Anxiety Disorder  Generalized Anxiety Disorders, Acute Anxiety  Anxiety due to specific stressful life event(s)  Other applications* Substance withdrawal As Hypnotic / Sedative Anti-Anxiety - Indications * Primarily for Benzodiazepines

21. www.SBCounty.gov Page 21 Behavioral Health  Anxiety Symptoms Excessive worry & anxiety Restlessness or feeling on edge Easily Fatigability Difficulty concentrating Irritability, Muscle tension Sleep disturbances *Symptoms cause significant distress in daily social functioning  Neuropsychiatric basis of treatment GABA receptors, Serotonin, Chloride ions Anti-Anxiety - Treatment of Symptoms

22. www.SBCounty.gov Page 22 Behavioral Health  SSRIs First line treatment for Anxiety disorders  Fluoxetine (Prozac)  Paroxetine (Paxil, Paxil-CR)  Sertraline (Zoloft)  Citalopram (Celexa)  Escitalopram (Lexapro)  Effexor, Effexor XR –FDA approved for Generalized Anxiety Disorder  Duloxetine (Cymbalta) Anti-Anxiety - Medications

23. www.SBCounty.gov Page 23 Behavioral Health  Benzodiazepines Alprazolam (Xanax / Nirivum) Clonazepam (Klonopin) Diazepam (Valium) Lorazepam (Ativum)  Non-Benzodiazepine Buspirone (BuSpar) Hydroxyzine (Vistaril, Atarax) Anti-Anxiety – Medications (continued)

24. www.SBCounty.gov Page 24 Behavioral Health  SSRIs  No immediate relieve of anxiety symptoms  Safer long term side effect profile  Anxiolytic Benzodiazepines Most common  Sedation, Ataxia, Dizziness, Cognitive impairment, Anterograde amnesiae Respiratory depression Abuse, Dependence  Tolerance, Cross-tolerance, Withdrawal Anti-Anxiety - Adverse Reactions

25. www.SBCounty.gov Page 25 Behavioral Health  Indications Principle applications  Treatment of Mania and Bipolar Disorders  Mood Disorders including Schizoaffective Disorder  Cyclothymia, Unipolar Depressions Other applications  Impulse Control Disorders  Severe Personality Disorder  Neuropsychiatric basis of treatment Second messenger system (Inositol, Arachidonic Acid, Phospholipase- A2) Mood Stabilizers - Indications

26. www.SBCounty.gov Page 26 Behavioral Health  Mood stabilizers Standard mood stabilizers  Lithium (Eskalith, Eskalith CR, Lithonate)  Valproate/ Divalproex (Depakene, Depakote)  Carbamazepine (Tegretol) Newer mood stabilizers  Lamotrigine (Lamictal)  Topiramate (Topamax)  Oxcarbazepine (Trileptal) Mood Stabilizers - Medications

27. www.SBCounty.gov Page 27 Behavioral Health  Lithium Most common  GI side effects ~ nausea and vomiting, Fine tremor, ‘Fuzzy feeling’ Less common  Renal…Polyuria, polydipsia, Diabetes Insipidus  Thyroid…Hypothyroidism  Dermatological…Rash & Acne  Neurological…muscle weakness, slurred speech (transient)  Cardiac…EKG changes, Edema  Hematological…Benign Leukocytosis Mood Stabilizers - Adverse Reactions

28. www.SBCounty.gov Page 28 Behavioral Health  Lithium toxicity Symptoms  Nausea, Vomiting, Diarrhea, Coarse tremor, Ataxia, Headache, Slurred speech, Confusion & Cardiac arrhythmia may occur Causes  Reduced fluid intake, Increased fluid & electrolytes loss (Excessive sweating, Diarrhea), Overdose  Drug interaction (Increased level by Diuretics, Non Steroidal Anti Inflammatory) Adverse Drug Reactions (continued)

29. www.SBCounty.gov Page 29 Behavioral Health  Neurotransmitter related reactions* Anti-cholinergic reactions  Dry mouth, Constipation, Urinary retention, Blurred vision Anti-alpha adrenagic reactions  Orthostatic hypotension, Sedation, Techycardia Anti-histamine reactions  Sedation, fatigue, Weight gain*, Hyperglycemia* Anti-dopamine reactions  Parkinson like symptoms (masked faces, tremors, dystonia, shuffling gait)  Hyper Prolactinemia (Galactorrhea)  Akathisia Miscellaneous  Hyper/hypothermia, photosensitivity, lower seizure threshold, rash, EKG changes (QT interval), Agranulocytosis Neurotransmitter Related Reactions *Anti-5HT1C ~ new warning for all Antipsychotic medications

30. www.SBCounty.gov Page 30 Behavioral Health  How to get a mentally ill patient to: Take their medications? Stay on their medications? Treatment Challenges

31. www.SBCounty.gov Page 31 Behavioral Health  What about forced medications? Treatment Challenges (continued)

32. www.SBCounty.gov Page 32 Behavioral Health  When do you know the patient is stabilized on medications? Treatment Challenges (continued)

33. www.SBCounty.gov Page 33 Behavioral Health  Development of a Release Team to ensure a warm hand off of patients to community providers upon release.  Increase in patients receiving follow up mental health and substance use services in the community after release. Community Reentry

34. www.SBCounty.gov Page 34 Behavioral Health Thank you! Teresa Frausto, M.D. Chief Medical Officer County of San Bernardino Department of Behavioral Health