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?

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

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.

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!

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

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. 2012. -

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

Mental Health by the Numbers In the past year: 1 in 10 teens ages 16-17 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 2014 http://www.samhsa.gov

Mental Health: Unmet Needs Needs are not always met 1 in 10 teens ages 16-17 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

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

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

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, 2013. Results from the 2012 National Survey on Drug Use and Health

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

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

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

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

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

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

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?

Educate before you Medicate www.talkaboutrx.org

Script Yourx Future

Prescription Labels

Over-the-Counter Labels

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

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

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

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

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)

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

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

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

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

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

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. www.fda.gov Kratochvil CJ, et al. J Child Adolesc Psychopharmacol; 2006;16:11-24

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®)

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

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

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

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

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

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

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

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

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

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

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

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

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

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!

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 http://www.internetdrugcoupons.com/ Get price quotes -GoodRx (www.goodrx.com) offers price comparisons Ask about medication samples

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

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.

Lasting Thoughts

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

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

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

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

Where do I get more information NAMI Information on Treatment http://www.nami.org/template.cfm?section=About_Treatments_and_Supports NAMI On Campus http://www.nami.org/Content/NavigationMenu/Find_Support/NAMI_on_Campus1/NAMI_on_Campus.htm

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