1. Mental Health in the Schools: Collaboration, Communication and Medications Elizabeth Reeve MD HealthPartners

2. Email  Elizabeth.A.Reeve@HealthPartners.com

3. Today’s Content  Collaboration Stakeholders Goals Problems  Communication Teachers, parents, psychologists, others  Diagnosis  Medications in the classroom Side effects, monitoring

4. Collaboration  One other thing- I was not comfortable passing out the ADHD forms you wanted filled out by teachers, coaches... I do not want him to be negativiely stereotyped any more than he already is. It doesn't help his self esteem. I'll bring in 4 of them, however, filled out by myself, my husband, and our daughters who've lived on their own now for yrs but know the situation quite well.

5. Collaboration  Stakeholders and Goals The individual student versus the school Whose best interest is being considered “The rights” of the student  IEP and 504s

6. Collaboration  Parent problems Fears of being “labeled” Unrealistic expectations for teachers and MDs  Physician problems Lack of time to communicate with teachers  Teacher schedule versus MD schedule Lack of reimbursement

7. Collaboration  Teacher/School problems Lack of contact with the physician Pull between the needs of the school and the needs of the individual student Medical goals may not be the same as the academic goals  Symptom treatment versus educational goals

8. Communication  Use of rating scales  Release of information How much should the school know Fears from the family that the school will know too much  The need for school data in order to confirm diagnostic issues Social data, attention, learning

9. Diagnosis  School: ASD MD thinks they have ADHD and an expressive language delay  Physician: Anxiety and LD School thinks they are oppositional and should be in an EBD room  Parental confusion?  Does the diagnosis matter?

10. Medications  Basic principles  Stimulants, SSRI’s, mood stabilizers, antipsychotics What are the uses Side effects that impact the school setting and/or learning

11. Basic Principles  There is no match between diagnosis and specific pharmacologic treatment Example: ADHD maybe treated with stimulants, nonstimulants, antidepressants  Drug choice is made by the presence of a symptom, not by virtue of a diagnosis For example: antipsychotics may be used for: augmentation in the treatment of anxiety and depression, psychosis, mood instability, aggression, explosive behavior or autism

12. So………  Identify the target symptom  Then choose the medication

13. The Seven Deadly Sins  Don’t treat  Failure to set a target symptom  Start meds but don’t adjust  Start meds but adjust too much  Setting the wrong expectations  Failure to monitor  Continuing medications with no efficacy

18. Medication Comparison: Methylphenidate Products

19. Medication Comparisons: Dexedrine Products

21. Ritalin ® LA: Extended-release Delivery via SODAS ™ Technology SODAS ™ is a trademark of Elan Corporation, Plc

22. Metadate CD

23. Adderall XR

24. Daytrana

25. Common Stimulant Side Effects  Appetite loss (expected)  Insomnia  Tics  Headache  Nausea  Rebound irritability  Growth suppression

26. Common Issues With Stimulants  Most children adolescents are under dosed  OK to increase dose rapidly  There is no efficacy difference between various stimulants

27. Other Medications for Attention, Hyperactivity  Atomoxetine (Strattera) Non-stimulant Needs to be given everyday Takes weeks to work Can be refilled over the phone May be better for persons with anxiety Primary side effects  Sedation, nausea and vomiting, weight loss,

28. Other Medications for Attention, Hyperactivity  Clonidine or Tenex Need to be given everyday, multiple doses each day Take weeks to work Main side effect is sedation  Wellbutrin Given every day Risk of seizures Needs to be given 24/7 Takes weeks to work

29. Stimulant Issues in School  Students will not eat lunch Appetite suppression is expected  What time do the meds wear off?  They don’t work if you don’t take them  Bothersome tics  Are there other reasons for attention problems? Learning issues, anxiety

32. Selective Serotonin Reuptake Inhibitors  Fluoxetine (Prozac)  Fluvoxamine (Luvox)  Paroxetine (Paxil)  Sertraline (Zoloft)  Citalopram (Celexa)  Escitalopram (Lexapro)

33. SSRI’s  There is no efficacy difference between any of the SSRI’s All are potentially equally beneficial for depression and anxiety  Individuals have different responses but there are not group efficacy differences The anxiety disorders that can be treated with an SSRI include GAD, Separation Anxiety, Social Anxiety Disorder, OCD, Panic Disorder, PTSD. Elective Mutism

34. SSRI’s  All SSRI’s have the same general potential side effects Restlessness, akathesia Insomnia or fatigue Appetite changes, increased or decreased GI upset Headaches Sexual dysfunction

35. SSRI’s  Serotonin syndrome Can happen with any SSRI, as well as other me serotinergic effect such as venlafaxine, clomipramine, fenfluramine Rapid onset Symptoms related to flood of extracellular 5HT May be frightening for the patient  trembling, shivering, fever, chills, clonus, hyperreflexia, may seem ataxic Treat with support and 5HT blockers  cyproheptadine and chlorpromazine

36. SSRI’s  SSRI withdrawal Paroxetine probably the worst Does not happen with fluoxetine  Characterized by flu-like syndrome Fever, shaking, fatigue, sweating, nausea, diarrhea Usually starts within 24-36 hours and resolves within 2-3 days, although may last longer  Treat by restarting medication and slowing down the taper

37. Choosing an SSRI  Knowledge of the parent about a particular drug  Side effect differences Weight gain, sedation, activation  Past history  Cost

38. Other Antidepressants  Buproprion A great antidepressant but it does not help anxiety  Venlafaxine and duloxetine are both serotonergic and noradrenergic reuptake inhibitors. Should help for both depression and anxiety  Trazodone and mirtazpine are used most often as sleep aids rather then antidepressants

39. SSRI Issues in School  Restlessness A common side effect and may show itself as aggression or irritability  Take weeks to work  Emergence of suicidal thinking Fact or fiction Assessing suicidality  Sexual dysfunction

42. Mood Stabilizers  Old Lithium Depakote Carbamazepine  New Oxcarbamazepine Gabapentin Lamotrogine Topiramate Others

43. Mood Stabilizers  A wide variety of uses Bipolar Disorder Augmentation in depression Explosive behavior Mood irritability Conduct disorder

44. Side Effects  Lithium Weight gain Acne Increased thirst and urination May effect thyroid and kidneys Cognitive impact  Depakote Weight gain Polycystic ovaries Osteoporosis

45. Mood Stabilizer  Topiramate “Dopamax” Sedation  Lamotrogine Rash

47. Antipsychotics: Old or New?  The Old Haldoperidol Thioridazine Thiothixene Proclorpromazine Perphenazine Fluphenazine  The New Clozapine Risperidone  Paliperidone Olanzapine Ziprasidone Aripiprazole Quetiapine

48. Differences Between Old and New  Old Less expensive Weight gain Elevated prolactin Tardive dyskinesia Few trials with kids and adolescents  New More expensive Some may have less weight gain Some may have less prolactin change May cause less tardive More research in kids and adolescents

49. Metabolic Syndrome  All antipsychotics may cause an increase in cholesterol, triglycerides, and risk for diabetes  Draw baseline labs and record weight HgbA1c, fasting lipid panel  Check labs at least yearly, perhaps sooner if significant weight gain

50. Weight Gain  Weight gain contributes to low self esteem and medication non compliance  Medical consequences of excessive weight HTN, DM, sleep apnea, PCOS, joint and back pain

51. Weight Gain for Each Drug  The literature suggests that the relative risks for diabetes, weight gain, and elevated lipids is as follows: Clozapine = Olanzapine > Risperidone = Quetiapine > Aripiprazole = Ziprasidone  The additional use of Depakote or lithium may increase the risks

52. Issues At School With Antipsychotics  Weight gain Self esteem, lethargy, hunger Enlist the help of school nurse  NO SCHOOL LUNCH  Restlessness  Sleepiness  Other movement issues

53. School Lunch  The elementary school lunches average 821 calories per lunch with 30 percent fat  The biggest problem, is that students can choose food items from the a la carte lines that are not as balanced and nutritious as the actual school meal. “The dietary guidelines for the a la carte line hasn’t been updated since the 1970s,”

54. School Lunch  Updated recommendations 500 calories for breakfast and 650 for lunch for kindergarten through fifth grade 550 for breakfast and 700 for lunch for kids in sixth to eighth grade 600 for breakfast and 850 for lunch for high school students

57. Questions????