Managing and Accommodating Students on Psychotropics and Other Medications that Affect Mental Health Job Corps National Health and Wellness Conference Las Vegas, Nevada April 15, 2009 David P. Kraft, MD, MPH Region I Mental Health Consultant John Sommers-Flanagan, Ph.D. Center Mental Health Consultant Trapper Creek Job Corps Center

Objectives 1.Psychotropic medications (PMs) most used by Job Corps students 2.Describe how to manage safe use of PMs in Job Corps 3.Describe ways to case manage students who need PMs 4.Describe empowerment strategies for student who need PMs 5.Example-Hear Trapper Creek students engage in medication monitoring 6.Possible accommodations for students on PMs 2

1. PMs Most Used by Job Corps Students (Spring 2008) Study—Data collection May-June 2008 –Questionnaire completed by HWM with assistance for 1 week during survey time –N = 122 centers completed survey –Total On-Board Strength = 40,470 –Total Students on Psychotropic Meds = 2,339 3

1. PMs Most Used by Job Corps Students (Spring 2008) Results showed –Average percent students on PMs = 6% –Range from 0% to 27% on PMs –When did they start PMs? –Arrived on PMs = 3% (50% on PMs) –Resumed PMs = 1% (17% on PMs) –Started PM on center = 2% (33% on PMs) –How many PMs are they on? –One PM = 3.5% (65% on PMs) –2-3 PMs = 1.7% (32% on PMs) –4 or more PMs= 0.3% ( 3% on PMs) 4

1. PMs Most Used by Job Corps Students (Spring 2008) Category of PMs Used – Antidepressants2.5% (33% on PMs) – Stimulants2% (26% on PMs) – Mood Stabilizers1% (12% on PMs) – Antipsychotics1% (12% on PMs) – Hypnotics0.5% (8% on PMs) – Antianxiety Agents0.5% (7% on PMs) – Other0.1% (2% on PMs) 5

1. PMs Most Used by Job Corps Students (Spring 2008) Funding So urces –Insurance (include Medicaid)41% [Lost Medicaid due to move = 19%] –Center Funds46% –Free Samples 7% –Other (e.g., grants) 2% 6

2. Describe How to Manage Safe Use of PMs in Job Corps Principles of safe use of Psychotropic Medications –Most PMs take 2 weeks to begin to work (except sedatives and stimulants) –New start of PMs give 5 days of side- effects--body will adjust if taken daily –Most medications are taken once a day, or may get withdrawal and start- up effects if skip doses 7

2. Describe How to Manage Safe Use of PMs in Job Corps Principles of safe use of PMs (cont’d) –“Black-box”: for antidepressants, mood stabilizers and antipsychotics, may get some suicidal ideas in first 2-4 weeks of use, before desired effects begin (NOT actually increase completed suicides). Need to have student check in periodically. –Use of PMs by Problem (Appendix 1) 8

2. Describe How to Manage Safe Use of PMs in Job Corps General principles of safe use in JC –Control amount of abusable PMs in residence halls, e.g., sedatives (benzo’s) and stimulants (limit to 1-2 days, to keep other students from taking them) –Use longer acting forms of sedatives and hypnotics, if possible (more expensive) 9

2. Describe How to Manage Safe Use of PMs in Job Corps General principles of safe use (cont’d) –Seek advice from HWC staff if adverse reactions All centers should have psychiatrist consultant, regarding possible problems, to advise center MD about case management –Warn student against stopping medications on own while in training program—save changes in medications for vacations, so not upset ability to learn when school is in session 10

2. Describe How to Manage Safe Use of PMs in Job Corps Non-PM approaches to problems –Depression: talk out sad feelings, regular exercise, Cognitive Behavior Therapy (CBT) –Anxiety: deep breathing, exercise, relaxation exercises, meditation –Insomnia: eliminate caffeine after supper, exercise, regular bedtime –Anger/explosive behavior: “count to 10”, walk away before saying anything, time- out room, exercise 11

2. Describe How to Manage Safe Use of PMs in Job Corps Non-PM approaches to problems (cont’d) –Psychotherapy methods, short-term: Cognitive Behavior Therapy (CBT) Dialectical Behavior Therapy (DBT) Relationship Therapy Reality Therapy Psychosocial Therapy Brief Psychodynamic Psychotherapy 12

3. Describe Ways to Case Manage Students who Need PMs At initial arrival on center –If student recently stopped medications, restart immediately (due to 2 week start-up) –Screen suspicious symptoms through CMHC, even if decided to re-start medications –If student stops medications, emphasize student’s responsibility for succeeding in program, and consequences if still needs medications, but cannot study successfully without them 13

3. Describe Ways to Case Manage Students who Need PMs During Training Program –If PMs stop working, consider raising dose, to overcome rapid metabolism of medications by liver –If loses control, consider MSWR to allow time to regain control with medication adjustment –If newly diagnosed depression or anxiety, have screened by CMHC, for support –If medication adjustments are needed, inform staff with a “Need-to-Know” (NTK), with student’s permission, to help support student 14

3. Describe Ways to Case Manage Students who Need PMs Planning for Graduation/Separation –If on medication, develop plan to transfer medication/therapy services to community where he/she moves –Help student learn process of life-long care for own needs –Consider using JAN to help with transition planning and arrangements 15

4. Describe Empowerment Strategies for Students who Need PMs Helping students manage medications –CMHC and “Introduction to Center Life” integration Non-coercive approach A pill is not a skill You are responsible for your behaviors Counseling and intern resources (180 extra hours of counseling each semester) –Initial physician visit –Medication explanations and framing 16

4. Describe Empowerment Strategies for Students who Need PMs SSRI-related adverse events and other target symptoms –3-12% of adolescents experience SSRI-related adverse events (very wide response range) –Common adverse events: Behavioral activation or mania or akathisia Suicide ideation/self-harm/violent thoughts Insomnia Gastrointestinal distress (vomiting, diarrhea, pain) Headaches 17

4. Describe Empowerment Strategies for Students who Need PMs Listening to students and their experiences –General motivational interviewing questions –Specific symptom-based questions –Reflecting and amplifying student contributions to symptom reduction 18

4. Describe Empowerment Strategies for Students who Need PMs Differential Activation Theory –Students with a history of suicidality may be more prone to having their symptoms reactivated –A constructive interview protocol can help activate and reactivate personal strengths and coping resources 19

4. Describe Empowerment Strategies for Students who Need PMs Communication and case management strategies –Establish a collaborative and personal responsibility mind-set in students and staff as described –Adhere to FDA recommendations for supportive weekly monitoring first four weeks and biweekly monitoring the next four weeks 20

4. Describe Empowerment Strategies for Students who Need PMs Communication and case management strategies (cont’d) –The four reality therapy (choice theory and personal responsibility) questions What do you want? What are you doing? Is it working? Should you make a new plan? 21

5. Example-Hear Trapper Creek Students Engage in Medication Monitoring Video clips 22

6. Possible Accommodations for Students on Psychotropic Medications Utilizing the IDT/reasonable accommodation team to plan for success with students on PMs 23

References Job Corps, PRH, TAG-H: Mental Health Disabilities [on Job Corps website] Maxmen JS, Kennedy SH, McIntyre RS. Psychotropic Drugs: Fast Facts. New York, W. W. Norton & Company,

Appendix 1: PMs used for Various Problems Depression –Selective Serotonin Reuptake Inhibitors (SSRIs)— fluoxetine (Prozac), sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), escitalopram (Lexapro), fluvoxamine (Luvox), trazodone (Desyrel) –Serotonin Norepinephrine Reuptake Inhibitors (SNRIs)—venlafaxine ER (Effexor XR), duloxetine (Cymbalta), desvenlafaxine (Pristiq) –Atypical Antidepressants—bupropion (Wellbutrin), doxepin (Serzone) –Tricyclic Antidepressants (TCAs)—amitriptyline (Elavil), imipramine (Tofranil), desipramine (Norpramine), etc. 25

Appendix 1: PMs used for Various Problems (cont’d) Anxiety –Immediate: Benzodiazepines ( BDZ)— lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium)—effective immediately, but addictive –Long Term: SSRIs, buspirone, SNRIs, TCA’s, antihistamines (hydroxyzine, diphenhydramine) 26

Appendix 1: PMs used for Various Problems (cont’d) Bipolar Mood Swings –Lithium carbonate (needs blood tests) –Anticonvulsants: divalproex (Depakote), carbamazepine (Tegretol, Carbatrol), lamotrigine (Lamictal), oxcarbazepine (Trileptal), topiramate (Topamax) –Antipsychotics: olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), risperidone (Risperdol), paliperidone (Invega), clozapine (Clozaril) 27

Appendix 1: PMs used for Various Problems (cont’d) Psychotic Disorders –Antipsychotics: olanzapine (Zyprexa), quetiapine (Seroquel), aripiprazole (Abilify), ziprasidone (Geodon), risperidone (Risperdol), paliperidone (Invega), clozapine (Clozaril) –Anticonvulsants: divalproex (Depakote), carbamazepine (Tegretol), lamotrigine (Lamictal), oxcarbazepine (Trileptal), topiramate (Topamax) 28

Appendix 1: PMs used for Various Problems (cont’d) Impulsive/Explosive Disorders –SSRIs –Antipsychotics –Lithium –Beta-blockers—propranolol (Inderal) [high dose], nadolol 29

Appendix 1: PMs used for Various Problems (cont’d) Attention Deficit/Hyperactivity Disorder –Antidepressants: fluoxetine (Prozac), buproprion (Wellbutrin), desipramine –Stimulants: methylphenidate (Ritalin), amphetamine salts (Adderall), dextroamphetamine (Dexedrine), –Stimulants: long-acting forms (Adderall- XR, Focalin-XR, Concerta-ER, Metadate- ER, Daytrana patch, Vyvanse) –Non-Stimulants: atomoxetine (Strattera), modafinil (Provigil) 30

Appendix 1: PMs used for Various Problems (cont’d) Sedative/Hypnotics –Benzodiazepines ( BDZ)—lorazepam (Ativan), clonazepam (Klonopin), alprazolam (Xanax), diazepam (Valium)—effective immediately, but addictive –Antihistamines—hydroxyzine (Vistaril, Atarax), diphenhydramine (Benadryl) –Antidepressants—trazodone (Desyrel) –Antipsychotics—quetiapine (Seroquel), thioridazine (Mellaril) 31

Appendix 2: Case Examples of Students on Psychotropic Medications History of ADHD with good response to stimulant medications, but seems poorly organized off medications, very forgetful. Does not want to restart medication— considers it a sign of weakness. What would you advise? History of depression, on antidepressant medications for 2 years, feeling “normal” and wants to stop medication. How would you advise? 32

Appendix 2: Case Examples of Students on Psychotropic Medications (cont’d) History of depression, started medications 3 weeks before arrival, still symptomatic. How would you handle? Bipolar Disorder for over 6 years, stabilized for last year, on same meds, but ran out a week ago, went 5 days without, restarted yesterday, but out of control. What would you advise? 33

Appendix 2: Case Examples of Students on Psychotropic Medications (cont’d) History of an antipsychotic medication needed for paranoia, but recently stopped 2 weeks ago, and appears fine. How would you advise? 34