PSYCHOPHARMACOLOGY POLICY

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PSYCHOPHARMACOLOGY POLICY

• Adverse Reactions to Psychotropics and Their
  Possible Side Effects

DJJ Mental Health Training Team
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PSYCHOPHARMACOLOGY POLICY
This class is intended for Division of Juvenile
Justice staff working with youth who are
prescribed psychopharmacologic agents
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POLICY OVERVIEW
This policy helps establish core principles of
evidence-based psychopharmacologic treatment
This class is intended for Division of Juvenile
Justice staff working with youth who are
prescribed psychopharmacologic agents
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TOPICS FOR DISCUSSION

• New psychopharmacology policy
• Various mental health disorders and their
  pharmaceutical treatments
• Common vs. serious side effects of psychotropics

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TIERED MEDICATION SYSTEM
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TIERED MEDICATION SYSTEM
TIER I

TIER II
TIER III

TIER IV
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TIERED MEDICATION SYSTEM
Tier II - Antipsychotics
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TIERED MEDICATION SYSTEM
Tier II Antidepressants
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TIERED MEDICATION SYSTEM
Tier II Mood Stabilizers
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TIERED MEDICATION SYSTEM
Tier II Anxiolytics
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TIERED MEDICATION SYSTEM
Tier II Sedative Hypnotic and Anti-Eps Agents
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TIERED MEDICATION SYSTEM
Tier II Stimulants and Miscellaneous
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TIERED MEDICATION SYSTEM
Tier III
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TIERED MEDICATION SYSTEM
Tier IV
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PSYCHOPHARMACOLOGY TREATMENT
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PHARMACISTS RESPONSIBILITIES(AS STATED IN THE
POLICY)
1. Pharmacist will be given a copy of Informed
Consent for Psychotropic Medications (DJJ XXXX)
by the prescribing psychiatrist at the time of
the initial order
2. The pharmacist shall document on the
medication administration record (MAR) the date
the form was signed

• The pharmacist cannot dispense Tier II, III or IV
  medication unless the order includes
  authorization on the correct form
• Authorized Exceptions exist for emergency
  circumstances or with a documented verbal
  authorization

3. If the appropriate forms are not included with
the psychiatrists order, the pharmacist will
contact the psychiatrist for clarification, to
obtain additional information and/or
authorization, and will note the contact in the
computerized medication order
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REGISTERED NURSES RESPONSIBILITIES (AS STATED IN
THE POLICY)
Prior to administering the medication, the nurse
is responsible for ensuring there is a current
consent on file.
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PSYCHOTROPIC MEDICATION

• Key issues you NEED to know
• Much is still unknown
• Large vs. small youth
• Risks and benefits of medicating
• Risks of not medicating
• Individualized responses to meds

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COMMON vs SERIOUS SIDE EFFECTS
Definition of side effect an unintended
consequence specifically arising from drug therapy

• Can be beneficial or deleterious
• Usually temporary but some are permanent

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COMMON vs SERIOUS SIDE EFFECTS

• Any medication can cause a serious allergic
  reaction
• Skin rash or hives
• Difficulty breathing
• Swelling of face, lips, tongue or throat
• Serious side effects are rare
• GET MEDICAL HELP!

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WITHDRAWAL SYNDROME

• Abruptly stopping medications can have negative
  consequences
• Youth should only discontinue their psych meds
  under the supervision of a psychiatrist
• SSRI discontinuation syndrome
• flu-like symptoms, headaches, insomnia, nausea,
  imbalance, sensory disturbances, and hyperarousal

These symptoms usually are mild, last 1 to 2
weeks, and are rapidly extinguished with
reinstitution of antidepressant medication
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ADHD MEDICATIONS

• Ritalin
• Cylert
• Dexedrine
• Adderall
• Concerta
• Metadate
• Strattera
• Tricyclic antidepressants

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ADHD MEDICATIONS
Common Side Effects

• Ritalin / Concerta / Dexedrine
• Nervousness
• Insomnia
• Dizziness
• Palpitations
• Tachycardia
• Anorexia
• Weight loss
• Tolerance
• Euphoria
• Dry mouth

• Straterra
• Stomach aches
• Diminished appetite
• Nausea
• Vomiting
• Dizziness
• Fatigue
• Mood swings

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ANXIETY DISORDERS

• Generalized anxiety disorder
• Obsessive-compulsive disorder
• Acute stress disorder
• Post-traumatic stress disorder
• Panic disorder
• Social Anxiety
• Specific phobias

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ANXIETY MEDICATIONS
Selective Serotonin Re-uptake Inhibitors (SSRIS)
(used for both anxiety and depressive disorders)

• Prozac
• Zoloft
• Paxil
• Celexa
• Luvox
• Lexapro

Not a complete list
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ANXIETY MEDICATIONS
SSRI Common Side Effects

• Headache
• Drowsiness
• Decreased libido
• Anorexia
• Excessive sweating
• Suicidal ideation
• Nervousness
• Anxiety
• Constipation

• Weight gain or loss
• Sexual dysfunction
• Self-injurious behavior
• Insomnia
• Agitation
• Dry mouth
• Nausea
• Sleep disturbance
• Photosensitivity

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Selective Serotonin Re-uptake Inhibitors (SSRIS)
Adverse reactions

• If a youth seems to have more thoughts about
  suicide, he should be referred that day to his
  therapist and to the unit psychiatrist for an
  urgent evaluation.
• You may give him some reassurance that it is
  probably his medication, and ask him what he
  needs to feel safer.
• This increase in suicidal thoughts decreases
  after the first month of treatment

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MOOD DISORDERS

• Major depression
• Severe sadness or lack of interest lasting at
  least 2 weeks
• Disruptions in ability to function
• High risk of suicide
• Poor concentration, anhedonia, psychomotor
  retardation, sleep disturbance, guilt, lethargy
• Dysthymia low grade depression thatlasts gt2
  years

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MOOD DISORDER MEDICATIONS

• SSRIs
• Prozac
• Zoloft
• Paxil
• Celexa
• Lexapro
• Luvox

• Other antidepressants
• SNRIs
• TCAs
• Imipramine
• Norttiptyline
• Desipramine
• Amitriptyline
• (Evavil, Pamelor, Doxepin)

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MOOD DISORDER MEDICATIONS
SSRI Side Effects

• Weight gain or loss
• Sexual dysfunction
• Self-injurious behavior
• Insomnia
• Agitation
• Dry mouth
• Nausea
• Sleep disturbance
• Photosensitivity

• Headache
• Drowsiness
• Decreased libido
• Anorexia
• Excessive sweating
• Suicidal ideation
• Nervousness
• Anxiety
• Constipation

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DEPRESSIVE DISORDER MEDICATIONS
TCA Side Effects

• Drowsiness
• Dizziness
• Orthostatic hypotension
• Tachycardia
• EKG changes
• Dry mouth
• Constipation
• Urinary retention
• Skin rash

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MOOD DISORDERS OTHER MEDICATIONS

• Cymbalta
• Effexor/Pristiq
• Remeron
• Wellbutrin
• Trazadone

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MOOD DISORDERS OTHER MEDICATIONS
SIDE EFFECTS

• Cymbalta
• Stomach pain
• Low fever
• Loss of appetite
• Dark urine
• Clay-colored, black, bloody, or tarry stools
• Jaundice (yellowing of the skin or eyes)
• Restlessness
• Overactive reflexes
• Hallucinations
• Loss of coordination

• Fainting
• Coma
• Nausea
• Vomiting
• Diarrhea
• Fever
• Fast heartbeat
• Easy bruising or bleeding
• Nosebleeds

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MOOD DISORDERS OTHER MEDICATIONS
SIDE EFFECTS

• Effexor / Pristiq
• Increased blood pressure (severe headaches,
  blurred vision)
• Nausea
• Vomiting
• Diarrhea
• Fever
• Fast heatbeat
• Hallucination
• Loss of coordination

• Fainting
• Coma
• Seizure
• Extreme thirst with headache
• Nausea, vomiting and weakness
• Easy bruising or bleeding

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MOOD DISORDERS OTHER MEDICATIONS
SIDE EFFECTS

• Remeron
• Fever
• Chills
• Body aches
• Flu symptoms
• White patches or sores on inside of mouth or lips
• Feeling might pass out

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MOOD DISORDERS OTHER MEDICATIONS
SIDE EFFECTS

• Wellbutrin
• Agitation
• Constipation
• Dizziness
• Dry mouth
• Excessive sweating
• Headache

• Headache
• Vomiting
• Skin rash
• Sleep disturbances
• Tremor
• Increased risk for seizure

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MOOD DISORDERS OTHER MEDICATIONS
SIDE EFFECTS

• Trazadone
• Light headed
• Headache
• Fever
• Flu-like symptoms
• Chest pain

• Problems urinating
• Dizziness
• Drowsiness
• Pripism

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REVIEW
ANTIDEPRESSANT and ANXIOLYTIC SIDE EFFECTS

• Agitation or lethargy
• Increased suicidal thoughts
• Discontinuation syndrome
• GI upset
• Dizziness
• Insomnia
• Risk of seizure (Wellbutrin)
• Onset of a hypomanic or manic episode

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PSYCHOTIC DISORDERS

• Schizophrenia
• Schizoaffective disorder
• Delusional disorder
• Psychotic features of MDD
• Bipolar disorder
• PTSD
• Quasi-psychotic features of personality disorders

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PSYCHOTIC DISORDER SYMPTOMS

• Hallucinations visual, auditory, tactile,
  gustatory
• Delusions paranoia, grandeur, bizarre
• Thought disorder disorganized, tangential,
  circumstantial, flight of ideas, loose
  associations
• Disorders of speech echolalia, word salad, clang
  associations
• Depersonalization, dissociation

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ANTI-PSYCHOTIC MEDICATIONS

• Newer Generation
• (Atypicals)
• Geodon
• Seroquel
• Risperdal
• Zyprexa
• Clozaril
• Aripiprazole
• Paliperidone

• Older Generation (Typicals)
• Haldon
• Thorazine
• Trilafon

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ANTI-PSYCHOTIC MEDICATIONS
Side Effects

• Sedation / insomnia
• Tardive dyskinesai (lip smacking)
• Hyperglycemia
• Dystonia (muscle stiffness)
• Extra-pyramidal side effects (EOS)
• Akathisia (restlessness)
• Constipation
• Drooling

• Diabetes
• Weight gain
• Headache
• Blurred vision
• Dry mouth
• Nausea
• Vomiting
• GI upset

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ANTI-PSYCHOTIC MEDICATIONS
Severe Adverse Effects

• Neuroleptic Malignant Syndrome
• Fever
• Muscle rigidity
• Muscle pain
• Drowsiness
• Cognitive changes (i.e. delirium, cannot focus
  disoriented

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BIPOLAR I AND II DISORDERS

• Severe mood swings
• Depression that is of a major depression
• Mania
• 1 week or longer
• Insomnia, distractible, overly goal-focused,
  hyperactive, psychotic, grandiose, risk taking,
  pressures, loud speech
• HIGH risk of suicide
• Hypomania
• Milder than mania
• Lasts 4 or more day to approximately 1 week

Underlying genetic risk of Bipolar disorder or
undiagnosed can be sent into a manic phase by
administering antidepressants
UNIT PSYCHIATRIST MUST BE INFORMED THAT DAY
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BIPOLAR DISORDER MEDICATIONS

• Mood stabilizers
• Anti-seizure medications
• Antidepressants
• Antipsychotics
• Combination of medications

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MOOD STABILIZERS
Side Effects

• Lithium
• Weight gain
• Scarring acne
• Hair thinning
• Pronounced tremor
• Kidney disease

• Anticonvulsants
• Nausea
• Dizziness
• Hands/arms trembling
• Blurred or double vision
• Sleep disturbances
• Shakiness
• Irritability
• Excitability

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MOOD STABILIZERS
Signs of Toxicity

• Anorexia
• Confusion
• Rash
• Coma
• Somnolence
• Seizures
• Heart attack
• Palpitations
• Blood pressure
• Headaches

• GI upset severe nausea and vomiting
• Ataxia (gait disturbance)
• Trouble with eyesight
• Severe lightheadedness
• Fever or hypothermia
• Tremors, chorea (flinging/flailing arms and legs)
• Dizziness
• Hallucinations
• Irritability

MUST CONTACT MEDICAL AND PSYCHIATRIST URGENTLY
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REVIEW

• Mood stabilizers and anti-seizure meds are the
  primary medications
• Toxicity is very important to notice and inform
  medical right away
• Antidepressants may cause switching to mania
• HIGH RISK FOR SUICIDE

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SUMMARY RECOMMENDATIONS

• Be very watchful of any youth you know is taking
  psychotropics
• Report changes in
• behavior
• coordination
• health
• mental functioning
• emotional functioning
• Significant changes in any of these areas in any
  youth should be reported to a physician right away