Psychotropic Medication in Treatment Courts Teresa Frausto MD Chief Medical Officer April 13 2016 No conflict of interest Disclaimer History of the mentally ill in corrections Review common diagnosis and medication treatments ID: 613627
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California Criminal Justice Reform: Recidivism Reduction Training
Psychotropic Medication in Treatment Courts
Teresa Frausto, M.D.
Chief Medical Officer
April 13, 2016Slide2
No conflict of interest.
DisclaimerSlide3
History of the mentally ill in corrections.
Review common diagnosis and medication treatments.Discuss treatment challenges.
Goals of PresentationSlide4
Origins of the Community Mental Health System
Deinstitutionalization of the severely mentally ill led to the trans institutionalization to the jails and prisons.
Funding from the cost savings achieved through the closures of the state hospitals to the community mental health system did not occur.
Unlike services to persons with developmental disabilities, the mental health system was never conceived as an “entitlement.”
Mental health services were to be provided “to the extent resources are available
.”Slide5
Although deinstitutionalization was well intentioned, the failure to provide treatment needs to the severely mentally ill has turned this policy into one of the greatest social disasters of the 20
th century.
Origins of the Community Mental Health SystemSlide6
Release of lower level offenders from the prisons back into the community.
Establishment of the Day Reporting Centers.Change in the population of the jails with more acute and chronic medical and mental health problems.
Assembly Bill 109Slide7
Most Commonly Used
Antipsychotics;Antidepressants;Antianxiety (Anxiolytic
);Mood Stabilizers;
Psychostimulants; andOthers.
Psychotropic MedicationsSlide8
Indications
Psychotic symptomsSchizophrenia, Schizoaffective
Psychotic Symptoms
Other applicationsDelirium/dementia
Substance induced psychosis/agitationSevere aggression and violence behaviors
Severe Personality disorder
Antipsychotics - IndicationsSlide9
Psychotic Symptoms
Positive symptoms Hallucinations, delusion, disorganization, Agitation
Negative symptomsAlogia (speech), Avolition (drive), Anhedonia (pleasure), Apathy (flat affect)
Antipsychotics - Treatment of SymptomsSlide10
Atypical Antipsychotics
Clozapine (Clozaril)Risperidone (Risperdal) >>> (Risperdal Consta)
Olanzapine (Zyprexa, Zydis)>> (Zyprexa Relprev)*Quetiapine (Seroquel, Seroquel XR)
Ziprasidone (Geodon)Aripiprazole (Abilify)Paliperidone (Invega) >>> (Invega Sustenna)*
Iloperidone (Fanapt)*Asenapine (Saphris)*
Lurasidone (Latuda)*
Antipsychotic
- Medications
* Newer AP & Long Acting injectable APSlide11
Sedation,
weight gain and cognitive dulling Extrapyramidal symptoms (EPS)
Diabetes, Hypertension, increases in Cholesterol
Cardiac changes – for example arrhythmias
Antipsychotic - Adverse ReactionsSlide12
Antidepressant - Indications
Indicators
Depressive Disorders
Major Depression
Dysthymia, Depression not otherwise specified
Anxiety Disorders
Panic
disorders, Social
Phobia
Post-traumatic Stress Disorder (PTSD)
Other
applications
Eating disorders, Obsessive Compulsive Disorder
Premenstrual Dysphoric Disorder
Migraine, pain disorders, impulse control disordersSlide13
Depressive Symptoms
Pervasive depressed mood, Excessive guilt feelings, hopeless & helplessnessPsychomotor agitation or retardation
Severe sleep disturbancesAnhedonia, poor concentration
Preoccupation with physical healthDelusional / Suicide thoughts
Antidepressant - Treatment of SymptomsSlide14
Traditional Antidepressants*
Monoamineoxidase Inhibitors(MAOI)Phenelzine (Nardil)Tranylcypromine (Parnate)
Tricyclic Antidepressants (TCAs)Amitryptyline (Elavil)
Imipramine (Tofranil)Doxepin (Sinequan)
Clomipramine (Anafranil)**
Antidepressant - Medications
* Able to measure therapeutic drug level
**
Mainly for OCDSlide15
Traditional Antidepressants
(continued)Nortryptyline (Pamelor)Desipramine (Norpramin)
Protryptyline (Vivactil)Trimipramine (Surmontil)Amoxapine (Arsendin
)
Antidepressant – Medications (continued) Slide16
Newer Antidepressants
Serotinin reuptake inhibitors (SSRIs)Fluoxetine (Prozac)Paroxetine (Paxil, Paxil-CR)Sertraline (Zoloft)
Citalopram (Celexa)
Escitalopram (Lexapro)Fluvoxamine (Luvox / Luvox CR)*Vortioxetine (Brintellix)
Antidepressant – Medications
(continued)
* Primarily for OCDSlide17
Newer
Antidepressants (continued)Serotonin-Norepinephrine reuptake inhibitors
Venlafaxine (Effexor, Effexor XR)Duloxetine (Cymbalta)
Desvenlafaxine (Pristiq)Levomilnacipran (Fetzima)
Antidepressant – Medications
(continued) Slide18
Other Atypical Antidepressants
Mirtazapine (Remeron)Bupropion (Welbutrin, Welbutrin SR, Wellbutrin XL)Trazodone (Desyrel)
Vilazodone (Viibryd)Vortioxetine (Brintellix)
Antidepressant – Medications
(continued) Slide19
Orthostatic Hypotension
Dizziness, TachycardiaSedations, Weight gainHypertensive CrisisDry mouth, blurred vision,
constipationConduction disturbancesSeizures
Tremors, Ataxia, Delirium (toxic level)Erectile & ejaculatory dysfunctions
Antidepressant - Adverse ReactionsSlide20
Anxiety Disorders
Panic Disorder, Phobias including Social Anxiety DisorderGeneralized Anxiety Disorders, Acute Anxiety
Anxiety due to specific stressful life event(s)Other applications*Substance withdrawal
As Hypnotic / Sedative
Anti-Anxiety - Indications
*
Primarily for BenzodiazepinesSlide21
Anxiety Symptoms
Excessive worry & anxietyRestlessness or feeling on edge
Easily FatigabilityDifficulty concentrating
Irritability, Muscle tensionSleep disturbances
*Symptoms cause significant distress in daily social functioning
Neuropsychiatric basis of treatment
GABA receptors, Serotonin, Chloride ions
Anti-Anxiety - Treatment of SymptomsSlide22
SSRIs
First line treatment for Anxiety disordersFluoxetine (Prozac)Paroxetine (Paxil, Paxil-CR)
Sertraline (Zoloft)Citalopram (Celexa)
Escitalopram (Lexapro)Effexor, Effexor XR –FDA approved for Generalized Anxiety Disorder
Duloxetine (Cymbalta)
Anti-Anxiety
-
Medications Slide23
Benzodiazepines
Alprazolam (Xanax / Nirivum)Clonazepam (Klonopin)Diazepam (Valium)
Lorazepam (Ativum)
Non-Benzodiazepine Buspirone (BuSpar)
Hydroxyzine (Vistaril, Atarax)
Anti-Anxiety – Medications
(continued) Slide24
SSRIs
No immediate relieve of anxiety symptomsSafer long term side effect profileAnxiolytic Benzodiazepines
Most common
Sedation, Ataxia, Dizziness, Cognitive impairment, Anterograde amnesiaeRespiratory depression
Abuse, DependenceTolerance, Cross-tolerance, Withdrawal
Anti-Anxiety - Adverse ReactionsSlide25
Indications
Principle applicationsTreatment of Mania and Bipolar Disorders
Mood Disorders including Schizoaffective Disorder
Cyclothymia, Unipolar Depressions
Other applicationsImpulse Control Disorders
Severe Personality Disorder
Neuropsychiatric basis of treatment
Second messenger system (Inositol, Arachidonic Acid, Phospholipase-A2)
Mood Stabilizers - IndicationsSlide26
Mood stabilizers
Standard mood stabilizersLithium (Eskalith, Eskalith CR, Lithonate)
Valproate/ Divalproex (Depakene, Depakote)Carbamazepine (Tegretol)
Newer mood stabilizersLamotrigine (Lamictal)
Topiramate (Topamax)Oxcarbazepine (Trileptal)
Mood Stabilizers - MedicationsSlide27
Lithium
Most commonGI side effects ~ nausea and vomiting, Fine tremor, ‘Fuzzy feeling’Less common
Renal…Polyuria, polydipsia, Diabetes Insipidus
Thyroid…HypothyroidismDermatological…Rash & Acne
Neurological…muscle weakness, slurred speech (transient)Cardiac…EKG changes, Edema
Hematological…Benign Leukocytosis
Mood Stabilizers - Adverse ReactionsSlide28
Lithium toxicity
SymptomsNausea, Vomiting, Diarrhea, Coarse tremor, Ataxia, Headache, Slurred speech, Confusion & Cardiac arrhythmia may occur
CausesReduced fluid intake, Increased fluid & electrolytes loss (Excessive sweating, Diarrhea), Overdose
Drug interaction (Increased level by Diuretics, Non Steroidal Anti Inflammatory)
Adverse Drug Reactions
(continued)Slide29
Neurotransmitter
related reactions*Anti-cholinergic reactionsDry mouth, Constipation, Urinary retention, Blurred visionAnti-alpha adrenagic reactions
Orthostatic hypotension, Sedation, Techycardia
Anti-histamine reactionsSedation, fatigue, Weight gain*, Hyperglycemia*
Anti-dopamine reactionsParkinson like symptoms (masked faces, tremors, dystonia, shuffling gait)
Hyper Prolactinemia (Galactorrhea)
Akathisia
Miscellaneous
Hyper/hypothermia, photosensitivity, lower seizure threshold, rash, EKG changes (QT interval), Agranulocytosis
Neurotransmitter Related
R
eactions
*Anti-5HT1C
~
new warning for all Antipsychotic medicationsSlide30
How to get a mentally ill patient to:
Take their medications?Stay on their medications?
Treatment ChallengesSlide31
What about forced medications?
Treatment Challenges (continued) Slide32
When do you know the patient is stabilized on medications?
Treatment Challenges (continued) Slide33
Development of a Release Team to ensure a warm hand off of patients to community providers upon
release. Increase in patients receiving follow up mental health and substance use services in the community after release.
Community Reentry Slide34
Thank you!
Teresa Frausto, M.D.
Chief Medical Officer
County of San Bernardino Department of Behavioral Health