1. Court Approval of Psychotropic Medication Role of the Attorney: Understanding Psychotropic Medications Principles and Concerns Michael Weinraub, M.D. Office (213) 526-6385 mweinraub@dmh.LAcounty.gov

2. What I Do at Edelman Court Referrals from Judges, minor’s attorneys and others with case questions and concerns Identify cases where biological causes and unmet medical conditions influence behaviors Review medications for side effects Review treatment programs for progress Ensure treating professionals are communicating on treatment plans and progress

3. Status of Psychotropic Medications in the American Marketplace –Industry research standards –Prescribing practices –After market monitoring –Ongoing studies in children –Black Box warnings Effexorer.com Depakoteer.com

4. Black Box Warning – SSRI’s

5. Depakote Black Box Warning Important Safety Information1,21,2 Hepatic failure resulting in fatalities has occurred in patients receiving valproic acid and its derivatives. Patients should be monitored closely for the appearance of nonspecific symptoms that may precede hepatotoxicity. Liver function tests should be performed prior to therapy and at frequent intervals thereafter, especially during the first 6 months. Valproate should not be administered to patients with hepatic disease or significant hepatic dysfunction. Children under the age of two years are at considerably higher risk of fatal hepatotoxicity. Valproate can produce teratogenic effects such as neural tube defects. Accordingly, the use of Depakote in women of childbearing potential requires that the benefits of its use be weighed against the risk of injury to the fetus. This is especially important when the treatment of a spontaneously reversible condition not ordinarily associated with permanent injury or risk of death (e.g., migraine) is contemplated. An Information sheet describing the teratogenic potential of valproate is available for patients. Cases of life-threatening pancreatitis have been reported with valproate, either initially or after several years of use. Some cases were described as hemorrhagic with a rapid progression from onset to death. Patients should be warned that symptoms of pancreatitis require prompt medical evaluation. If pancreatitis is diagnosed, valproate should be discontinued.

6. Principle One No medication will supplant the need of understanding what is going on in the mind of the child. –Behavior management with medication may bring rapid symptomatic relief. –Medications may provide initial cost savings. –Mental health problems persist until underlying problem is resolved.

7. Principle Two Starting Medication New to the Marketplace: –Do not be the first to use a new medication –Do not wait to be the last to try a new medication

8. Principle Three Prescribing practices: –Raise doses slowly –Add new and/or additional medications slowly –Educate caregiver to improve monitoring –Extreme caution with multiple medications of the same class –Monitor results with: Appropriate labs Height, weight, (BMI) and blood pressure

9. Body Mass Index Best way to evaluate obesity Correlates with body fat and is relatively unaffected by height BMI = Wt (kg)/Ht (m) x Ht (m) BMI =[Wt (lbs)/Ht (inches) x Ht (inches)] x 703

10. Classification of BMI in Children Underweight – <5 th percentile Normal weight – 5 th to <85 th percentile Overweight – > 85 th to < 95 th percentile Obese – > 95 th percentile

12. Principle Four Ask the child how the medication is affecting them: –Soon after starting a new medication or changing doses of a medication. –Do they feel the medication is helping them? –How do they feel? –How are they eating and sleeping?

13. Principle Five Psychotropic medications are given as an adjuvant to therapy –Therapy may need to be: Frequent Continuous with the same person Supported by caregiver participation

14. Principle Six Long Term Care Monitoring: –Review current diagnosis to see if consistent with current treatment –Consider lowering dose if working –Consider “wash out” if uncertain what underlying behaviors are being treated

15. Concerns Frequent disruptions in placement and stopping and starting medications Frequent changing medications without past Hx Loss of information of response to medications Medicating children who move frequently and who do not have a family and personal medical history Chemical control without therapeutic improvement Medicating preschoolers Prescribing Drugs that are Abused

16. Antipsychotic Medications Used in Children Used for psychotic episodes as well as to treat aggression, Bi-polar D/O (BPD), ADHD & … BPD is an increasingly controversial diagnosis Evidence atypicals improve children's lives with BPD is scarce Seroquel, Risperdal, Zyprexa, Geodon, Abilify

17. Metabolic Syndrome: Definition in children Triglycerides ≥ 110 mg/dl HDL ≤ 40 mg/dl (M & F) Waist circumference ≥ 90% (M & F) Fasting Blood Glucose ≥ 100 mg/dl Blood Pressure ≥ 90% Cook S., et al. Arch Pediatr Adolesc Med. 2003;157:821-7.

18.  Metabolic syndrome: other associations Fatty liver disease with steatosis Insulin Resistance Type 2 Diabetes Chronic kidney disease (GFR<60 mL/min, microalbuminuria Polycystic ovary syndrome Obstructive sleep apnea

19. Antidepressant Medications Used in Children Prozac, Zoloft, Paxil, Celexa, Lexapro Concern is for weight gain and increased sucididal ideation.

20. Stimulant Medication Used in Children Adderall, Ritalin, Dexedrine Other class: Strattera Look for history of preexisting structural cardiovascular conditions.

21. Mood Stabilizers Used in Children Depakote, Carbatrol, Lamictal, Trileptal Close monitoring of laboratory results Monitoring for increased SI Monitoring girls for PCOS

22. PMA Process Family and Medical History (?) Medical Examination – Organic causes (?) Therapy – What kind, by who, and how frequent (?) Medication Effects and Side Effects Informed Consent – Patient and Caregivers informed Coordinated Care – Is the team talking with each other (?)