1. Medication & Adolescents: Empowerment Through Education
Angela Campbell, Pharm.D., MS, BCPP
Tawny Smith, Pharm.D., BCPP

2. Outline
List common psychiatric conditions medications may help with in children and adolescents
Discuss specific psychotropic medication side effects or warnings
Discuss FDA approval for medications in children and adolescents
Understand medication-taking behaviors in adolescents
List tips for providing medication education to adolescents

3. Using Psychiatric Medications in Children & Adolescents

4. Medication Treatment of Psychiatric Disorders in Children and Adolescents
What psychiatric conditions may be treated with medications?
Depression
ADHD
Anxiety disorders
Bipolar Disorder
Psychosis (Schizophrenia, Schizoaffective disorder, bipolar disorder with psychotic features, major depression with psychosis)
PTSD
OCD
Irritability associated with autism
Aggression when related to a psychiatric disorder

5. Symptoms & Diagnosis
In mental health, many diagnoses can have the same symptoms
Irritability: depression, bipolar disorder, substance abuse, autism
Aggression: bipolar disorder, ADHD, conduct disorder, disruptive behavior disorder, schizophrenia
Depression: major depression, bipolar disorder, schizophrenia

6. What is the relationship between diagnosis and medications?
There majority of psychotropic medications are used to treat more than one diagnosis
Antidepressants: depression, anxiety, OCD, PTSD, eating disorders
Antipsychotic medications: bipolar disorder, schizophrenia, schizoaffective disorder, irritability associated with autism, major depression (to augment antidepressant effects)

7. Possible Side Effects of Psychiatric Medications

8. Stimulants Examples: Amphetamine salts Methylphenidate
Adderall®/Adderall XR®
Methylphenidate
Ritalin®/Concerta®/Daytrana®
Dexmethylphenidate
Focalin®/Focalin XR®

9. Stimulants: Potential Side Effects
Most common side effect is decreased appetite
Small increases in heart rate and blood pressure may occur, but are not usually clinically significant
No increased risk of serious cardiac events
Use caution in people with existing heart problems
Structural abnormalities (i.e., coronary artery abnormalities, subaortic stenosis)
Chest pain, irregular heart beat, high blood pressure, or unexplained lightheadedness/fainting

10. Antidepressants Examples: Fluoxetine/Prozac® Sertraline/Zoloft®
Paroxetine/Paxil®/PaxilCR®
Citalopram/Celexa®
Escitalopram/Lexapro®
Fluvoxamine/Luvox®
Venlafaxine/Effexor®/ EffexorXR®
Duloxetine/Cymbalta®
Bupropion/Wellbutrin®/ WellbutrinSR®/ WellbutrinXL®
Amitriptyline/Elavil®
Nortriptyline/Pamelor®/ Aventyl®
Clomipramine/Anafranil®
Doxepin/Sinequan®
Imipramine/Tofranil®
Medications in this column typically used infrequently in children and adolescents

11. Antidepressants: Potential Side Effects
Commonly causes an increase in anxiety for the first 7-10 days of treatment
After this time, begins to help with anxiety
Monitor closely for new-onset or worsening suicidal thoughts or actions (FDA black box warning)
Particularly during first two weeks of antidepressant treatment
Increased irritability, aggression, worsening depression, anxiety, decreased need for sleep, or impulsivity could indicate a switch to mania or worsening suicidality

12. Antidepressants
The majority of studies have found that antidepressants have a protective effect against suicide
Benefits of antidepressants appear to be greater than the risk of suicidal ideation/suicide

13. Antidepressants How should the FDA warning be interpreted?
Increased risk of suicidality possible during first few weeks of treatment with antidepressants
Assessment, careful and accurate diagnosis, and monitoring are of the utmost importance
Nonmedication treatment alternatives should be tried first, if possible
Antidepressants should be used in children and adolescents who require medication treatment for depression
Initial assessment of suicidality is critical, as is ongoing monitoring for suicidal thoughts/plans
Know what symptoms to watch for and be aware of

14. Behavior changes that indicate young person needs help
Sudden drop in grades
Changes in friends or personality
Constant thoughts and fears about their personal safety or safety of family members
Does not want to go to school
New or frequent complaints of headache, stomach aches, and other sicknesses
Trouble sleeping or nightmares
As children of all ages grow, they experience a variety of mood, behavior, personality changes: normal.
Need for help: Difficult for them to manage resulting in several different symptoms lasting for more than a few weeks; usually causes difficulties in more than one setting: home, school, social settings, etc.
As children of all ages grow, they experience a variety of mood, behaviors, and personality changes, and this is normal. However, sometimes young people begin to experience mental health issues that become difficult for them to manage resulting in several different symptoms lasting for more than a few weeks. Only a licensed medical doctor or mental health professional can provide an evaluation to determine whether or not your child has a mental health or substance abuse problem.

15. Behavior changes that indicate young person needs help (continued)
Prolonged feelings of sadness and loneliness
Doesn’t care about favorite activities or is “too tired to play”
Feels angry, getting into fights
Trouble sitting still or concentrating
Running away
Noticeable weight loss or gain
Talks about death/suicide

16. Antipsychotics Examples: Chlorpromazine/ Thorazine®
Aripiprazole/Abilify®
Asenapine/Saphris®
Clozapine/Clozaril®
Iloperidone/Fanapt®
Lurasidone/Latuda®
Olanzapine/Zyprexa®
Paliperidone/Invega®
Quetiapine/Seroquel®
Risperidone/Risperdal®
Ziprasidone/Geodon®
Chlorpromazine/ Thorazine®
Fluphenazine/Prolixin®
Haloperidol/Haldol®
Loxapine/Loxitane®
Molindone/Moban®
Perphenazine/Trilafon®
Trifluoperazine/ Stelazine®
Thioridazine/Mellaril®
Thiothixene/Navane®

17. Antipsychotics: Potential Side Effects
Possibility for increased appetite and weight gain
Talk with doctor quickly if weight gain occurs; easier to address early on
Possibility to cause extrapyramidal side effects (EPS)
Sudden onset of very stiff muscles/spasms
Restlessness, inability to sit still
Rigid joints, pill-rolling tremor, stiff walk

18. Antipsychotics: Potential Side Effects
Possibility to cause an increase in prolactin levels
Change in menstrual cycle, absence of menstrual cycle, breast growth (males or females), lactation (males or females)
Not a medical emergency, but let your doctor know!
Doctor may need to adjust dose or switch medications

19. Lithium
Possible side effects: stomach upset, diarrhea, ↑ appetite, weight gain, less clear thinking, feeling tired, shakiness, acne
Laboratory monitoring is very important!
Can affect the thyroid and kidneys
Can monitor drug levels
Many things can increase lithium levels
Low salt diet, dehydration, NSAIDs (i.e., ibuprofen, naproxen), some blood pressure medications

20. Depakote ® (divalproex, valproic acid)
Possible side effects: shakiness, weight gain, stomach upset/nausea, dizziness, hair loss,
Laboratory monitoring is important!
Can affect the liver, pancreas
Can cause decreased platelets and increase ammonia
Can monitor drug levels

21. Tegretol ® (carbamazepine)
Possible side effects: feeling tired, stomach upset, thinking not as clearly, dizziness, rash
Laboratory monitoring is important!
Can cause unsafe blood cell count problems (rare)
Can cause low blood sodium levels
Can monitor drug levels
Interacts with many other medications

22. Lamictal® (lamotrigine)
Possible side effects: stomach upset, headache, skin rashes, dizziness, feeling tired
If rash develops, call MD right away, and stop taking lamotrigine
Rash can worsen and become very serious requiring medical attention, especially if person continues taking lamotrigine

23. The Food and Drug Administration (FDA) and Psychotropic Medications in Children & Adolescents

24. The Food and Drug Administration and Medications in Children and Adolescents
In order for a medication to gain “FDA approval,” the company who makes a medication must conduct a study to show it is safe and effective
Many psychotropic medications do not have FDA approval in children and adolescents
Studies may not be conducted in pediatric patients for many reasons
The FDA does not regulate physician or other healthcare provider prescribing of medications
The FDA states it “does not limit the manner in which a practitioner may prescribe an approved drug”
Studies and expert clinical opinion often support the “off label” use of medications
Psychotropic Medication Utilization Parameters in Foster Children and Youth, DFPS 2013

25. The Food and Drug Administration and Medications in Children and Adolescents
Many medications are used “off-label” in children and adolescents
Often, there are many studies to support that a medication is safe and effective, even if there is not FDA approval
Discuss with your doctor if you have concerns
Ask if there is evidence to support the use of that medication in children or adolescents (It is okay to ask this question!)

26. Medication-taking Behaviors in Adolescents

27. Adolescents and Medications
“We should not assume that youth have understood their illness, made sense of their medication treatment, or have adhered to the regimen as adults.”
“Health research has demonstrated that adolescents draw on personal perceptions, beliefs, and meanings in their experience of medical interventions.”
Example: youth with asthma may modify medical advice about asthma treatment when they believe their knowledge supersedes that of doctor
Floersch et al. Adolescent Experience of Psychotropic Treatment. Trancult Psychiatry 2009; 46:

28. Adolescents [and Medications]
May assert autonomy by resisting standard treatments
May not adhere to prescribed medications when they do not feel like taking medication
May choose not to take their medications when they feel “healthy”
May stop medications that prevent progression of illness or prevent relapse of illness when the medication does not provide the reinforcement of feeling well or immediate relief of physical symptoms
May stop taking medications because they feel well or no longer feel the medication is needed
Floersch et al. Adolescent Experience of Psychotropic Treatment. Trancult Psychiatry 2009; 46:

29. Adolescents and Medications
Studies have shown:
Adolescents may discontinue asthma medication when they do not recognize symptoms of the illness in themselves, such as shortness of breath (van Es et al. 1998)
Adolescents with chronic asthma may discontinue medications when they feel the medication is ineffective or feel they don’t have the illness (Buston & Wood 1999; van Es et al. 1998)
Adolescents with diabetes may resist treatment for diabetes or may not adhere to prescribed treatment when they don’t feel like taking medication (Adams et al. 1997; Kyngas & Hentinen 1995)
HIV positive adolescents may avoid taking antiretroviral medications when they feel healthy (Pugatch et al. 2002)
Floersch et al. Adolescent Experience of Psychotropic Treatment. Trancult Psychiatry 2009; 46:

30. Adolescents and Medications
Adolescents respond to medication treatment in profoundly different and personal ways that influence adherence and treatment effectiveness
The theme of expectation and hope seems particularly important in adolescent medication taking behavior
So, how can you encourage or influence adolescents to take medications?
Floersch et al. Adolescent Experience of Psychotropic Treatment. Trancult Psychiatry 2009; 46:

31. Providing Medication Education to Adolescents

32. Medication Education: Empowering Adolescents
What to discuss with adolescents and their families about their treatment:
De-stigmatize the experience of mental illness
Give education about the origins, time course, and treatment options for mental illness
Empower the child/family to get the help they need and to take charge/control of their own health and well-being
Guidelines for Adolescent Depression in Primary Care

33. Medication Education: Empowering Adolescents
Psychiatric medications are challenging because there is often a long delay before the medication effect “kicks in”
Aspirin for a headache → begins to work in about 30 minutes
Fluoxetine/Prozac™ for depression → begins to work in about 3-6 weeks
This is a long time to wait to feel better!!
Important to remind and educate teenagers of this, and to provide encouragement/motivation to continue taking the medication until it begins to help with symptoms
Keep the endpoint in mind!

34. Things adolescents want to know about mental illness:
How/why mental illness occurs
Typically occurs due to imbalances of brain chemicals, called neurotransmitters (too much or too little)
Often, genetics are involved
Stress or trauma is often implicated
Sometimes occurs randomly
Guidelines for Adolescent Depression in Primary Care

35. Things adolescents want to know about medications:
How psychiatric medications work:
By helping to regulate brain chemicals (neurotransmitters) which send signals to different parts of the brain and body
May help normalize the levels of these chemicals in the brain which in turn, improves symptoms of mental illness
Must take the medication CONSISTENTLY (every day) for it to help
Guidelines for Adolescent Depression in Primary Care

36. Things adolescents want to know about medications:
Specifically how the medication will help them:
improved mood
better concentration
more normal sleep
more normal appetite
greater interest in activities
more energy
Guidelines for Adolescent Depression in Primary Care

37. Things adolescents want to know about medications:
Will medication change who I am?:
Medication will not change who you are or make you different from other young people.
It will help you get back to the way you were before you became ill so that you feel like yourself again.
Taking medication is not much different than wearing glasses or braces – it’s only a tool to help you get well or feel better.
Guidelines for Adolescent Depression in Primary Care

38. Things adolescents want to know about medications:
Are psychiatric medications addicting? Will I become dependent on them?:
Definition of addiction: compulsive need for and use of a habit-forming substance (as heroin, nicotine, or alcohol) characterized by tolerance and by well-defined physiological symptoms upon withdrawal; broadly : persistent compulsive use of a substance known by the user to be harmful
Definition of dependence: the quality or state of being dependent; especially : the quality or state of being influenced or determined by or subject to another

39. Things adolescents want to know about medications:
Are psychiatric medications addicting? Will I become dependent on them? (continued):
Most psychiatric medications are not addicting and do not cause dependence
Antidepressants, antipsychotics, mood stabilizers, stimulants for ADHD
Some psychiatric medications have the possibility to be addicting. Generally these are only prescribed for short periods of time to limit the potential for addiction or dependence.
Benzodiazepines (lorazepam, clonazepam, alprazolam, etc.)
Some sleep medications (zolpidem/Ambien®, eszopiclone/Lunesta®, etc.)

40. Things adolescents want to know about medications:
Are psychiatric medications addicting? Will I become dependent on them? (continued):
Psychotropic medications get a “bad rap” for being addictive because they do have to be TAKEN to work or cause an effect (just like any medication). If they are not taken, relapse can occur.
Medications control symptoms and keep illness stable, but must be taken every day, usually long-term
Currently there is no “cure” for mental illness
Similar to having diabetes, asthma, or thyroid illness – need daily medication to manage/control mental illness

41. Things adolescents want to know about medications:
How long will I have to take the medication?:
If the medication is helpful and you have no problems with it, you will probably need to take the medications for a number of months, even after you feel better to make sure the symptoms are better.
In some cases (depending on which illness), medications may need to be taken for life.
Guidelines for Adolescent Depression in Primary Care

42. Things adolescents want to know about medications:
Are psychiatric medications safe to take long-term/for life?
YES!
Most medications have long studies (several years in duration) conducted to ensure safety with long-term use
There have been medication treatments for mental illness since the late 1950’s/early 1960’s
Guidelines for Adolescent Depression in Primary Care

43. Things adolescents want to know about medications:
Are psychiatric medications safe to take long-term/for life? (continued)
Usually side effects (unwanted effects) of meds occur early on in treatment, so possible to adjust or switch medications in order to find the right “one”
Guidelines for Adolescent Depression in Primary Care

44. Medication Education: Empowering Adolescents
What is my role in taking medications for mental illness?:
Learn what medication you take, how much to take, and what it is for
It is your responsibility to take medication in the right amount at the right time (may need help from parents/caregiver!)
Don’t take other medications without asking your doctor first, even over-the-counter medications
Never use alcohol or drugs while taking medication. It can be dangerous or deadly.
Talk with your doctor about any problems you experience while taking medications.
Even if you feel okay or good, take your medication every day
Guidelines for Adolescent Depression in Primary Care

45. Medication Education: Empowering Adolescents
Adolescents need to know whether compliance with medications is important (It is!) and the potential consequences of noncompliance
Medication may not work
Recurrence of illness or symptoms
Potential for hospitalization
Medication may not work as quickly/help as much after a relapse occurs
Stress that psychiatric medication has to be taken long-term (EVERY DAY)

46. Medication Education: Empowering Adolescents
Encourage the adolescent to self-evaluate and make notes of positive and negative aspects of taking the medication
Mood diary
Discuss these with the doctor
May remind adolescent often (daily if needed) about the link between symptoms, behaviors, and feelings and the rationale for taking medications

47. Strategies for Providing Medication Education to Adolescents

48. Medication Education: Teaching Adolescents
Important to make medication information RELEVANT to adolescents
Keep it real
Give realistic information about time medication typically takes to work
Give realistic expectations of response to medications or how well medication will potentially work
Give accurate but not overwhelming information about side effects
Give information about common side effects
Give information about “medical emergency” side effects and what to do if they occur (STRESS THAT THESE ARE RARE!)

49. Medication Education: Teaching Adolescents
Make YOURSELF relevant (Why should they listen to you?)
Helps to stay (at least a little) up-to-date with current events in adolescent pop culture
Make the information interesting
Make sure you know what you’re talking about
Teens respond to knowledgeable and relevant information
If you sound like (and do!) know what you’re talking about, they typically tune in

50. Medication Education: Teaching Adolescents
Make the information and delivery of the information interesting
Energetic delivery
Use examples
Use stories
Use humor
Work in current events related to your educational topic
Substance abuse example: Lil Wayne recently hospitalized when he had a seizure after ingesting “sizzurp/purple drank” (i.e., phenergan with codeine cough syrup)

51. Learning Tools Jeopardy-type board games
Educational reading material or websites

52. Jeopardy Board Game

53. Jeopardy Board Game

54. Learning Tools Jeopardy-type board games
Educational reading material or websites

55. Questions?