Medication and Treatment Challenges for the Young Adult Karen Moeller, PharmD, BCPP Clinical Associate Professor The University of Kansas School of Pharmacy.

Medication and Treatment Challenges for

the Young AdultKaren Moeller, PharmD, BCPP

Clinical Associate ProfessorThe University of Kansas

School of Pharmacy

Heidi Wehring, PharmD, BCPPAssistant Professor

The University of MarylandSchool 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: youth suicide. 2012. -

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?

• StigmaStigma

• “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 MedicationsHow 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

• 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• 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 intakeIncrease physical exerciseEat green leafy vegetables Talk with doctor or pharmacist about mild laxatives

Tiredness Talk to your doctor about switching entire daily dosage at bedtimeTake 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 SevereContact your doctor• 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?

• Antipsychotics

• Antidepressants

• Mood Stabilizers

• Stimulants

• Antianxiety/ Hypnotics

AntipsychoticsTypical Antipsychotics

• chlorpromazine (Thorazine®)• thioridazine (Mellaril®)• loxapine (Loxitane®)• molindone (Moban®)• perphenazine (Trilafon®)• trifluoperazine (Stelazine®)• thiothixene (Navane®)• fluphenazine (Prolixin®)*• haloperidol (Haldol®)*

Atypical Antipsychotics• Clozapine (Clozaril®)

• Olanzapine (Zyprexa®)*

• Risperidone (Risperdal®)*

• Paliperidone (Invega®)*

• Quetiapine (Seroquel®)

• Ziprasidone (Geodon®)

• Aripiprazole (Abilify®)*

• Asenapine (Saphris®)

• Iloperidone (Fanapt®)

• Lurasidone (Latuda®)

*Available in a Long Acting Injection (usually take every 2 weeks or monthly)

Side Effects of Antipsychotics

• Drowsiness– Some are more than other– Usually resolves in a few week

• Anticholinergic Side Effects– 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)– Dystonias– Pseudoparkinsonism– Tardive Dyskinesias– Akathisias

Most Commonly seen with the typical

or older agents

Common Antidepressants• SSRIs

– Prozac® (Fluoxetine)– Zoloft® (Sertraline)– Paxil® (Paroxetine)– Celexa® (Citalopram)– Lexapro® (escitalopram)– Luvox® (Fluvoxamine)

• SNRIs– Effexor® (Venlafaxine)– Cymbalta® (Duloxetine)– Pristiq® (Desvenlafaxine)

• Others– Wellbutrin® (bupropion)– Remeron® (mirtazapine)

• Older Antidepressants (mainly used for sleep or other indications)– Trazodone– Amitriptyline– Doxepin

All Antidepressants have a suicide warning in people

<25 years old

SSRI and SNRI Side effects

• 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.govKratochvil 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 severeCall 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

• Anorexia/Wt loss• Stomach pain• Insomnia• Rebound Symptoms• Irritability• Depressed Mood• Zombie State

• Others– Hypertension– Hallucinations– Tics

Key PointsTalk with your doctor if you have a pre-exsisting heart

condition

Benzodiazepines

• Examples– Xanax® (alprazolam)– Valium® (diazepam)– Ativan® (lorazepam)– Klonopin® (clonazepam)– Librium®

(chlordiazepoxide)– Restoril® (temazepam)

Benzodiazepines – Side Effects

• 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 medications1. Pill Box

2. Ask your pharmacy if the “bubble pack” / “blister pack” or fill pill boxes

Helpful hints to remember to take your medications3. Make a Calendar

4. Set Alarms / Reminders

Helpful hints to remember to take your medications5. Smart Phone Apps (free)

– iPhone and Android• MyMedSchedule• MyMeds• MedSimple• PillManager

Helpful hints to remember to take your medications6. 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!

• 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

High Cost Medications

Using Your Medications Safely

• Avoid Alcohol and Street drugs while on psychiatric medication– Be up front about what you usually use

• 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• 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=About_Treatments_and_Supports

• NAMI On Campus

http://www.nami.org/Content/NavigationMenu/Find_Support/NAMI_on_Campus1/NAMI_on_Campus.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