Transcript A-1 - Medication and Treatment Challenges for Young Adults

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
Medication Challenges
Drugs don’t work in patients
who don’t take them.
— C. Everett Koop, M.D
Objectives
1. Review mental illnesses and substance
abuse risk in young adults.
2. Discuss risks and benefits of medications in
young adults.
3. 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:
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
– 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?
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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?”
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
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
Psychiatric Medications
How they work
• Relieve symptoms
• Help prevent return of symptoms
Medications Do Not Cure Mental Illness
Why do I Need to Take Medications?
Benefits of taking my medications
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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
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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!
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
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
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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?
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Antipsychotics
Antidepressants
Mood Stabilizers
Stimulants
Antianxiety/ Hypnotics
Antipsychotics
Typical Antipsychotics
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(Thorazine®)
chlorpromazine
thioridazine (Mellaril®)
loxapine (Loxitane®)
molindone (Moban®)
perphenazine (Trilafon®)
trifluoperazine (Stelazine®)
thiothixene (Navane®)
fluphenazine (Prolixin®)*
haloperidol (Haldol®)*
Atypical Antipsychotics
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*Available in a Long Acting Injection
(usually take every 2 weeks or monthly)
Clozapine (Clozaril®)
Olanzapine (Zyprexa®)*
Risperidone (Risperdal®)*
Paliperidone (Invega®)*
Quetiapine (Seroquel®)
Ziprasidone (Geodon®)
Aripiprazole (Abilify®)*
Asenapine (Saphris®)
Iloperidone (Fanapt®)
Lurasidone (Latuda®)
Side Effects of Antipsychotics
• Drowsiness
– Some are more than other
– Usually resolves in a few week
• Anticholinergic Side Effects
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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)
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Dystonias
Pseudoparkinsonism
Tardive Dyskinesias
Akathisias
Most Commonly
seen with the typical
or older agents
Common Antidepressants
• SSRIs
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• Others
Prozac® (Fluoxetine)
– Wellbutrin® (bupropion)
Zoloft® (Sertraline)
– Remeron® (mirtazapine)
Paxil® (Paroxetine)
Celexa® (Citalopram)
• Older Antidepressants
Lexapro® (escitalopram) (mainly used for sleep or other
indications)
Luvox® (Fluvoxamine)
• SNRIs
– Effexor® (Venlafaxine)
– Cymbalta® (Duloxetine)
– Pristiq® (Desvenlafaxine)
– Trazodone
– Amitriptyline
– Doxepin
All Antidepressants have a
suicide warning in people
<25 years old
SSRI and SNRI Side effects
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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®)
– 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
• Common
– 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
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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
Benzodiazepines
• Examples
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Xanax® (alprazolam)
Valium® (diazepam)
Ativan® (lorazepam)
Klonopin® (clonazepam)
Librium®
(chlordiazepoxide)
– Restoril® (temazepam)
Benzodiazepines – Side Effects
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Drowsiness
Clumsiness (ataxia)
Fatigue
Confusion
Memory problems
Slowed breathing
ADDICTION
Benzodiazepines
USE CAUTION WHILE DRIVING OR OPERATING
HEAVY MACHINERY
Hypnotics
• Risks of Addiction
®
– Lunesta (Eszopiclone)
®
– Sonata (Zaleplon)
®
– Ambien (Zolpidem)
– Benzodiazepines
• Non-addicting
– Trazodone
– Hydroxyzine
– Doxepin
– Rozerem
®
(Ramelteon )
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
Helpful hints to remember to
take your medications
1. Pill Box
2. Ask your pharmacy if the “bubble pack” /
“blister pack” or fill pill boxes
Helpful hints to remember to
take your medications
3. Make a Calendar
4. Set Alarms / Reminders
Helpful hints to remember to
take your medications
5. Smart Phone Apps (free)
– iPhone and Android
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MyMedSchedule
MyMeds
MedSimple
PillManager
Helpful hints to remember to
take your medications
6. 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
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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
• 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
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Be sure you have the correct dosage
Find out about different types of medications
Talk with your doctor about side effects
Avoid Medication interaction
Where do I get more information
• NAMI Information on Treatment
http://www.nami.org/template.cfm?section=Abou
t_Treatments_and_Supports
• NAMI On Campus
http://www.nami.org/Content/NavigationMenu/Fi
nd_Support/NAMI_on_Campus1/NAMI_on_C
ampus.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