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Psychotropic Medications and Clinical Practice
Children & Adolescents
Training for Clinicians
SFBHN
Psychotropic
Medications
Training
Daniel Castellanos, MD
Medical Director, South Florida Behavioral Health Network
2014
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Gralnik & Castellanos Nov 2013
This training about psychotropic medications was developed
for clinicians to help them make informed decisions and
monitor consumers who are prescribed these medications.
 This training reviews expectations for the safe and effective
use of psychotropic medications in the State of Florida.

Disclaimer
The author and SFBHN have used reasonable care and skill in compiling the content
of this training. However, we accept no responsibility or liability for any inaccuracy
or errors and omissions, or for any damage or injury to persons or property arising
out of the accessing or use of any of the materials contained in this presentation and
material accessed from it. Individual prescribers are responsible for their prescribing
practices. Specific questions about medications should be consulted with the
prescriber.
Psychotropic Medications Training 2014
Recognize common mental health disorders in children &
adolescents.
 Identify effective treatment options for these mental health
disorders.
 Identify the names and indications for use of commonly
prescribed psychotropic medications.
 Recognize how psychotropic medications are used.
 Recognize common psychotropic medication side effects.
 Identify your responsibilities in the treatment process.
 Identify what to do if you have concerns about the
psychotropic medications prescribed to consumers whose
care you are involved with.

Psychotropic Medications Training 2014


Psychotropic medications (sometimes called
psychotherapeutic medications) are used to treat
emotional and behavioral health symptoms and psychiatric
disorders.
They affect mood, thoughts, behaviors, and how a person
processes information and perceives his or her
surroundings.
Psychotropic Medications Training 2014
Psychotropic medication must not be used as a method of
discipline or control for any consumer.
 Psychotropic medications are not to be used instead of or
as a substitute for identified therapy or behavioral
interventions and supports required to meet a consumer’s
mental health needs.

Psychotropic Medications Training 2014

The FDA observes that accepted medical practice
includes medication use that is not reflected in approved
medication labeling. This is called “off label” use.

Many psychotropic medications that are not FDA
approved for a specific use can be used off label to
appropriately manage different and difficult problems.

Off label psychotropic medication use may be justified
when the benefits of treatment outweigh the risks.
Without treatment, these consumers could at times
suffer serious or dangerous consequences.
Psychotropic Medications Training 2014

General population:
 About 20% of children in the general population have some
form of a mental health disorder.
 Approximately 40% of youth have co-occurring disorders.

Foster care:
 The national range of children in foster care that have
significant mental health problems is 23-80%
 In Miami-Dade and Monroe Counties during FY 2011-2012,
approximately 82% of children in foster care had a
diagnosable Axis I mental health disorder.
 Even when compared to children in similar social class and
demographics, foster children are at greater risk for mental
health problems.
Psychotropic Medications Training 2014

General population:
 About 20% of children in the general population have
some form of a behavioral health disorder.
 Approximately 40% of youth have co-occurring
disorders.

Foster care:
 The national range of children in foster care that have
significant behavioral health problems is 23-80%
 Even when compared to children in similar social class
and demographics, foster children are at greater risk for
behavioral health problems.
Psychotropic Medications Training 2014


The most common disorders in children and adolescents
include:
 Anxiety Disorders
 Disruptive Behavior Disorders (ADHD, Oppositional
Defiant Disorder, Conduct Disorder)
 Depressive Disorders (Major Depressive Disorder and
Persistent Depressive Disorder/ FKA Dysthymic
Disorder)
 Substance Use Disorders (mainly adolescents).
Schizophrenia is not commonly found in childhood.
Psychotropic Medications Training 2014
Source: www.nami.org
Psychotropic Meds Training 2014

Mental health matters at every stage of life and requires an
integrated continuum of services ranging from prevention
to recovery.

Mental health can be improved:
 With earlier identification and intervention.
 With improved access to services at the right time.

By establishing best practices and improving standards
of care.

By coordinating mental health care across school,
medical and community environments.
Psychotropic Medications Training 2014
The Treatment Plan is a tool that helps coordinate, monitor
and guide treatment interventions.
 The Treatment Plan:
 Should be developed based on the best available
evidence.
 Involves a continuous process that is updated on a
regular basis and as needed.
 Defines target problems that will be the focus of
treatment.
 Defines the plan to monitor the child, short and long
term.

Psychotropic Medications Training 2014
A multitude of interventions may be indicated in helping
children in out of home care.
 Treatment may involve:
 Therapy
 Educational interventions
 Structure
 Medications

REMEMBER: Psychotropic medications should only be used
as one part of a comprehensive treatment plan.
Psychotropic Medications Training 2014






Many kinds of psychotherapies exist.
There is no "one-size-fits-all" approach.
Some therapies have been scientifically tested more than
others. The goal is to utilize more “Evidenced-Based”
therapies.
Sometimes psychotherapy alone may be the best treatment for
a person, depending on the illness and its severity.
Sometimes, psychotherapy is combined with medications.
The kind of psychotherapy a child receives depends on his or her
needs.
Psychotropic Medications Training 2014
Psychotropic Medications Training 2014
The classes of psychotropic medications to be reviewed are:
 Stimulants and Other Medications Used to Treat ADHD
 Antidepressants
 Antipsychotics
 Mood stabilizers
 Anxiolytics
 Miscellaneous:
√ Antihistamine Medications
√ Medications used to Treat Side Effects of
Antipsychotics
Remember: Not all medications your consumer is taking
may be covered here.
Psychotropic Medications Training 2014
Stimulants & Other
Medications Used to
Treat ADHD
SFBHN
Psychotropic Medications
Training
Psychotropic Medications Training 2014
Stimulants and other medications are commonly used
to treat Attention-Deficit/Hyperactivity Disorder
(ADHD).
 Symptoms of ADHD interfere with functioning at
school, work and in daily living and may include:




Short attention span.
Inability to stay still.
Being impulsive.
Psychotropic Medications Training 2014
Generic Name
Brand Name®
FDA Max
per day
Mixed Amphetamine salts
Adderall
40 mg
Yes
No
Mixed Amphetamine salts XR
Adderall XR
30 mg
Yes
Yes
Clonidine
Methylphenidate
Catapres *
Daytrana Patch
Concerta
Metadate CD
Ritalin LA
Quillivant XR
Dexedrine
Focalin
Focalin XR
Intuniv *
Kapvay *
Ritalin
Strattera *
Tenex *
Vyvanse
Wellbutrin SR/XL*
0.4 mg
30 mg
72 mg
60 mg
60 mg
60 mg
40 mg
20 mg
30 mg
4 mg
0.4 mg
60 mg
100 mg
4 mg
70 mg
300 mg
No
Yes
No
No
Yes
Yes
Methylphenidate ER
Dextroamphetamine
Dexmethylphenidate
Dexmethylphenidate XR
Guanfecine ER
Clonidine ER
Methylphenidate
Atomoxetine
Guanfecine
Lisdexamphetamine
Bupropion
FDA Approved for ADHD
Children & Adol
Adults
Yes
No
Yes
No
Yes
Yes
Yes
No
Yes
No
Yes
No
Yes
Yes
No
No
Yes
Yes
No
No
SFBHN Psychotropic Medications Training 2014
Groups:
 Stimulants:
 Usually first line/choice meds
 Controlled substances
 Amphetamine based
 Methylphenidate

Non-stimulant medications:
 NOT controlled substances
 Atomoxetine
 Clonidine, clonidine ER & guanfecine, guanfecine ER
 Others (typically off label)
Psychotropic Medications Training 2014
What does it mean that stimulants are controlled
substances by DEA (Schedule II)?:

One prescription supply only (usually one month)

No refills

Cannot be called in or faxed to the pharmacy
(Paper prescription is needed)

Potential for abuse
Psychotropic Medications Training 2014
Examples of stimulants (DEA Schedule II controlled
substances):

Mixed Amphetamine salts: Adderall , Adderall XR

Methylphenidate:
Ritalin , Daytrana Patch

Methylphenidate ER:
Concerta , Metadate CD , Ritalin LA
Quillivant XR
®
®
®
®
®
®
®

Dextroamphetamine:
Dexedrine

Dexmethylphenidate:
Focalin , Focalin XR

Lisdexamphetamine:
Vyvanse
®
®
®
Psychotropic Medications Training 2014
®










Decreased appetite
Stomachaches
Headaches
Trouble falling asleep
Irritability
Higher blood pressure and heart rate
Jitteriness
Being “too” quiet
Tics
Problems with growing
Psychotropic Medications Training 2014
Rare, Unexpected, Serious




Psychosis/Mania
Cardiovascular Risks (May include sudden cardiac death,
dizziness, chest pain, stroke and arrhythmias in persons with
serious pre-existing heart problems).
Skin rashes
Dependence
Psychotropic Medications Training 2014
Nonstimulants:
 Atomoxetine (Strattera®) - Side Effects:
 Stomach aches
 Increased liver enzymes
 Suicidal behaviors

Clonidine, clonidine ER/Kapvay® & guanfecine, guanfecine
ER/Intuniv® - Side Effects:
 Tiredness
 Sedation
 Headaches
 Stomach aches
 Lowering of blood pressure
Psychotropic Medications Training 2014
Psychotropic Medications Training 2014
Methylphenidate
Concerta®
Adderall XR®
Vyvanse®
Mean plasma levels (ng/mL)
20
15
Effective concentration
10
5
0
0
5
Time (hours)
10
SFBHN Psychotropic Medication Training 2014
Generic Name
Brand Name®
FDA Max
per day
Mixed Amphetamine salts
Adderall
40 mg
Yes
No
Mixed Amphetamine salts XR
Adderall XR
30 mg
Yes
Yes
Clonidine
Methylphenidate
Catapres *
Daytrana Patch
Concerta
Metadate CD
Ritalin LA
Quillivant XR
Dexedrine
Focalin
Focalin XR
Intuniv *
Kapvay *
Ritalin
Strattera *
Tenex *
Vyvanse
Wellbutrin SR/XL*
0.4 mg
30 mg
72 mg
60 mg
60 mg
60 mg
40 mg
20 mg
30 mg
4 mg
0.4 mg
60 mg
100 mg
4 mg
70 mg
300 mg
No
Yes
No
No
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
Yes
No
No
No
Yes
No
No
No
Yes
No
Yes
No
Methylphenidate ER
Dextroamphetamine
Dexmethylphenidate
Dexmethylphenidate XR
Guanfecine ER
Clonidine ER
Methylphenidate
Atomoxetine
Guanfecine
Lisdexamphetamine
Bupropion
FDA Approved for ADHD
Children & Adol
Adults
SFBHN Psychotropic Medications Training 2014
Antidepressants
SFBHN
Psychotropic Medications
Training
Psychotropic Medications Training 2014
Antidepressants are used in consumers to treat:
 Depressive disorders
 Anxiety disorders
 Obsessive-Compulsive Disorder (OCD)
 other conditions.
Psychotropic Medications Training 2014
Child & AdolescentOnly 2 antidepressants are FDA approved for the
treatment of major depressive disorder in children and
adolescents:


fluoxetine (Prozac; 8 – 17 yo)
escitalopram (Lexapro; 12 – 17 yo)
Psychotropic Medications Training 2014
Generic Name
Brand Name®
Vortioxetine
Citalopram
Duloxetine
Velanfaxine
Venlafaxine XR
Selegine
Fetzima
Brintellix
Celexa
Cymbalta
Effexor
Effexor XR
Emsam patch
Levomilnacipran CR
FDA Max
per day
20 mg
60 mg
60 mg
225 mg
225 mg
12 mg
120 mg
Escitalopram
Lexapro
30 mg
Fluvoxamine
Fluvoxamine CR
Paroxetine
Paroxetine CR
Desvenlafaxine
Luvox
Luvox CR
Paxil, Pexeva
Paxil CR
Pristiq
300 mg
300 mg
50 mg
62.5 mg
400 mg
Fluoxetine
Prozac
60 mg
Mirtazapine
Fluoxetine
Doxepin
Vilazodone
Bupropion
Remeron
Serafem
Silenor
Viibryd
Wellbutrin
Bupropion SR/XL
Wellbutrin SR/XL
45 mg
80 mg
6 mg
40 mg
450 mg
400 mg(SR) /
450(XL)
FDA Approved for
Major Depression
Adults
Adults
Adults
Adults
Adults
Adults
Adults
Children & Adol (12-17);
Adults
No
No
Adults
Adults
Adults
Children & Adol (8-17);
Adults
Adults
No
No
Adults
Adults
Adults
SFBHN Psychotropic Medications Training 2014
FDA Max
per day
FDA Approved for
Major Depression
Generic Name
Brand Name®
Clomipramine
Anafranil
200 mg (children/adol)
250 mg (adults)
No
Doxepin
Sinequan
300 mg
Adults
Trazodone
Desyrel
300 mg
Adults
Amitryptiline
Elavil
300 mg
Adults
Nortryptiline
Pamelor
200 mg
Adults
Imipramine
Tofranil
300 mg
Adults
SFBHN Psychotropic Medications Training 2014

Anxiety Disorders:
 Antidepressant medications have an anti-anxiety effect. Some
of these medications are considered first line medications (off
label) in the treatment of anxiety disorders in children and
adolescents.

Obsessive Compulsive Disorder (OCD):
 Certain antidepressants are FDA approved for the treatment
of OCD in children and adolescents:
 clomipramine (Anafranil)
 fluoxetine (Prozac)
 fluvoxamine (Luvox)
 sertraline (Zoloft).
Psychotropic Medications Training 2014

Antidepressant medications can be effective in the
treatment of other disorders.

In ADULTS Certain antidepressants are FDA approved for
the treatment of:
 Bulimia Nervosa
 Generalized Anxiety Disorder
 Obsessive Compulsive Disorder (OCD)
 Panic Disorder
 Premenstrual Dysphoric Disorder (PMDD)
 Posttraumatic Stress Disorder (PTSD)
 Social Anxiety Disorder (FKA Social Phobia)
Psychotropic Medications Training 2014
Generic Name
Brand Name®
Vortioxetine
Brintellix
Citalopram
Celexa
Duloxetine
Cymbalta
Velanfaxine
Effexor
Venlafaxine XR
Effexor XR
Selegine
Fetzima
Emsam patch
Levomilnacipran CR
Escitalopram
Lexapro
Fluvoxamine
Luvox
Fluvoxamine CR
Luvox CR
Paroxetine
Paxil, Pexeva
Paroxetine CR
Paxil CR
Desvenlafaxine
Pristiq
Fluoxetine
Prozac
Mirtazapine
Remeron
Fluoxetine
Doxepin
Vilazodone
Bupropion
Bupropion SR/XL
Serafem
Silenor
Viibryd
Wellbutrin
Wellbutrin SR/XL
Sertraline
Zoloft
Bulimia
Nervosa
Generalized Obsessive
Anxiety
Compulsive
Disorder
Disorder
Panic
Disorder
Premenstrual Posttraumatic
Social Anxiety
Dysphoric
Stress
Disorder
Disorder
Disorder























SFBHN Psychotropic Medications Training 2014







Headache
Nausea
Upset stomach
Trouble sleeping
Jitteriness
Dry mouth
Easily bruising
Psychotropic Medications Training 2014
Rare, Unexpected, Serious




Low blood sodium
Allergic reactions
Seizures (bupropion/Wellbutrin)
Mania.
Psychotropic Medications Training 2014
Child, Adolescents & Young Adults
A boxed warning is used by the FDA to alert doctors and patients
that special care should be exercised when using antidepressants:
“Antidepressants increased the risk compared to placebo of suicidal
thinking and behavior (suicidality) in children, adolescents, and young
adults in short-term studies of major depressive disorder (MDD) and
other psychiatric disorders.”
REMEMBER: Children, adolescents & young adults (< 24 yo) taking
an antidepressant should be monitored for new or worsened suicidal
thoughts and behaviors. Talk to the doctor or the prescriber if this
happens.
Psychotropic Medications Training 2014
SSRIs – FDA Category C pregnancy precaution: no
adequate and well-controlled studies in humans to
determine the effect of the SSRI on the fetus.
 Research findings on the effects of antidepressants on the
growing baby are mixed and inconclusive.
 Even though most risks found by researchers have been
low, the potential risk of a rare heart and lung condition
known as persistent pulmonary hypertension of the
newborn (PPHN) has been identified.
 Antidepressants should be used during pregnancy only if
the potential benefit justifies the potential risk to the fetus.

Psychotropic Medication Training 2014
Generic Name
Brand Name®
Vortioxetine
Citalopram
Duloxetine
Velanfaxine
Venlafaxine XR
Selegine
Fetzima
Brintellix
Celexa
Cymbalta
Effexor
Effexor XR
Emsam patch
Levomilnacipran CR
FDA Max
per day
20 mg
60 mg
60 mg
225 mg
225 mg
12 mg
120 mg
Escitalopram
Lexapro
30 mg
Fluvoxamine
Fluvoxamine CR
Paroxetine
Paroxetine CR
Desvenlafaxine
Luvox
Luvox CR
Paxil, Pexeva
Paxil CR
Pristiq
300 mg
300 mg
50 mg
62.5 mg
400 mg
Fluoxetine
Prozac
60 mg
Mirtazapine
Fluoxetine
Doxepin
Vilazodone
Bupropion
Remeron
Serafem
Silenor
Viibryd
Wellbutrin
Bupropion SR/XL
Wellbutrin SR/XL
45 mg
80 mg
6 mg
40 mg
450 mg
400 mg(SR) /
450(XL)
FDA Approved for
Major Depression
Adults
Adults
Adults
Adults
Adults
Adults
Adults
Children & Adol (12-17);
Adults
No
No
Adults
Adults
Adults
Children & Adol (8-17);
Adults
Adults
No
No
Adults
Adults
Adults
SFBHN Psychotropic Medications Training 2014
Psychotropic Medications Training 2014
FDA Max
per day
FDA Approved for
Major Depression
Generic Name
Brand Name®
Clomipramine
Anafranil
200 mg (children/adol)
250 mg (adults)
No
Doxepin
Sinequan
300 mg
Adults
Trazodone
Desyrel
300 mg
Adults
Amitryptiline
Elavil
300 mg
Adults
Nortryptiline
Pamelor
200 mg
Adults
Imipramine
Tofranil
300 mg
Adults
SFBHN Psychotropic Medications Training 2014
Antipsychotics
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Psychotropic Medications Training
Psychotropic Medications Training 2014

These medications may improve:
 Psychotic symptoms (eg, hallucinations, delusions, impaired
reality, disorganized thinking, etc).
 Bipolar mood changes, such as manic episodes; bipolar
depression less so.
 Depression, as an adjunct to antidepressants.
 Irritability, associated with autism spectrum disorder.
 Agitation or aggression.
Psychotropic Medications Training 2014
Antipsychotic medications are FDA approved to treat:
Schizophrenia spectrum & other psychotic disorders
 Bipolar and related disorders
 Major Depressive Disorder (augmentation)
 Autism Spectrum Disorder (irritability):

 Aripiprazole (Abilify)
 Risperidone (Risperdal)

Acute treatment of agitation:
 Aripiprazole (Abilify)
 Loxitane
(Adasuve#) - Inhaler
 Olanzapine (Zyprexa)
 Ziprasidone (Geodon)
Psychotropic Medications Training 2014
The following antipsychotic medications are FDA
approved for the treatment of schizophrenia in
adolescents 13-17 years:





aripiprazole (Abilify)
haloperidal (Haldol; 3-17 yo)
olanzapine (Zyprexa)
quetiapine (Seroquel)
risperidone (Risperdal).
Psychotropic Medications Training 2014
The following antipsychotic medications are FDA
approved for the treatment of acute manic or mixed
episodes associated with Bipolar I
Disorder in
youngsters 10-17 years:




aripirprazole (Abilify)
olanzapine (Zyprexa; 13-17 years only)
quetiapine (Seroquel)
risperidone (Risperdal).
Psychotropic Medications Training 2014
The following antipsychotic medications are FDA
approved for the treatment of the symptomatic treatment
of irritability associated with children and adolescents with
autistic disorder:


aripiprazole (Abilify)
risperidone (Risperdal)
Psychotropic Medications Training 2014
Schizophrenia
Generic Name Brand Name®
(13-17 yo)
Bipolar I
Disorder
(10-17 yo)
Aripiprazole
Abilify

Olanzapine
Zyprexa



(13-17)
Quetiapine
Seroquel


Risperidone
Risperdal

Haloperidal
Haldol


(03-17)
Autism
Spectrum
Disorder
(6-17 y0)


SFBHN Psychotropic Medications Training 2014
Generic Name
Brand
FDA Rec Max
Name®
per day
Aripiprazole
Abilify#
30 mg
Loxapine
Clozapine
Iloperidone
Ziprasidone
Adasuve
Clozaril
Fanapt
Geodon
Paliperidone
FDA Approved for
Schizophrenia
Mania/Bipolar
10 mg (Inhaled)
900 mg
24 mg
80 mg
Adol (13-17)
Adults
Adults- Agitation
Adults
Adults
Adults
Child & Adol (10-17);
Adults
Adults-Agitation
No
Adults
Adults
Invega
12 mg
Adults
Adults
Latuda
Lurasidone
160 mgSchizophrenia
120 mg-BPD
Depression
Adults
Adults (Bipolar
Depression only)
Risperidone
Risperdal#
8 mg
Adol (13-17)
Adults
Child & Adol (10-17);
Adults
Risperidone
Risperdal Consta*
50 mg/2 wks
Adults
Adults
Asenapine
Saphris
20 mg
Adults
Adults
Quetiapine
Seroquel
800 mg
Olanzapine
Zyprexa
20 mg
Adol (13-17);
Adults
Adol (13-17);
Adults
Child & Adol (10-17);
Adults
Adol (13-17);
Adults
# Also approved for use in children with Autistic Spectrum Disorder
* Long acting injection
SFBHN Psychotropic Medications Training 2014
Generic Name
Brand Name®
FDA Max per day
FDA Approved for
Schizophrenia
Child & Adol (3-17)
Mania/Bipolar
Haloperidal
Haldol◄
60 mg
Haloperidal
Haldol Decanoate*
300 mg/mo
Loxapine
Loxitane
250 mg
Thioridazine
Mellaril
800 mg
Thiothixene
Navane
60 mg
Pimozide
Orap ◄
No current brand
name exists
10 mg
No
No
40 mg
Adults
No
Fluphenazine
Prolixin Decanoate*
75 mg/2 wks
Adults
No
Trifluoperazine
Stelazine
80 mg
Chlorprmazine
Thorazine
2,000 mg
Fluphenazine
Perphenazine
Trilafon
◄ Approved for use in Tourette's Disorder
64 mg
* Long acting injection
Adults
Adults
No
Child & Adol (12-17)
Adults
Adults
Adults
Child & Adol (6-17)
Adults
Child & Adol (1-17)
Adults
No
No
Child & Adol (12-17)
Adults
No
No
No
No
No
SFBHN Psychotropic Medications Training 2014
Mania
Hypomania
Euthymia/Baseline
Maintenance
Bipolar Depression
Psychotropic Medications Training 2014
Mania
DMDD
Hypomania
Euthymia/Baseline
Maintenance
Bipolar Depression
Psychotropic Medications Training 2014
Generic Name
Major
Bipolar
Depressive
Brand Name®
Disorder
Depression
(Augmentation)

AgitationAcute
Treatment

Aripiprazole
Abilify
Loxapine
Adasuve

Ziprasidone
Geodon

Lurasidone
Latuda
Quetiapine
Seroquel


Quetiapine +
Fluoxetine
Symbyax


Olanzapine
Zyprexa


SFBHN Psychotropic Medications Training 2014
Most antipsychotics are associated with
decreased appetite and weight loss.
Most antipsychotics are associated with
decreased appetite and weight loss.













Drowsiness
Dizziness
Dry mouth
Blurred vision
Constipation
Stiffness
Restlessness
Drooling
Rapid heartbeat
Sensitivity to the sun
Skin rashes
Increased appetite and weight gain
Menstrual problems
Psychotropic Medications Training 2014
Rare, unexpected, serious






Enlargement of breasts in males
Galactorrhea (flow of milk from the breast when not pregnant)
Dangerous drop in white blood cells (clozapine).
Seizures (clozapine)
Tardive dyskinesia (TD; potentially irreversible involuntary
movements)
Neuroleptic malignant syndrome (NMS; increased temperature,
muscular rigidity, altered mental state, changes in kidney
functioning).
Psychotropic Medications Training 2014

QT prolongation (changes in heart’s electrical activity):
 May prolong QT interval and may be associated with
arrhythmia and sudden death.
 Use with caution in children and adolescents with
cardiovascular problems.
Psychotropic Medications Training 2014

Metabolic Changes:
 Atypical antipsychotic drugs have been associated with
metabolic changes that may increase cardiovascular/
cerebrovascular risk, such as:
 heart disease
 stroke
 diabetes
 These metabolic changes include:
 Increased blood sugar (hyperglycemia)
 Increased lipids (dyslipidemia)
 Weight gain
Psychotropic Medications Training 2014
Psychotropic Medications Training 2014
FDA Category C pregnancy precaution
 Antipsychotics are associated with increased gestational
weight & diabetes and with increased risk of preterm birth.
 Findings in relation to malformations are inconclusive.
 Potential risk for abnormal muscle movements
(extrapyramidal signs or EPS) and withdrawal symptoms in
newborns whose mothers were treated with these drugs
during the third trimester of pregnancy.
 Clozapine is considered a Category B medication.

Psychotropic Meds Training 2014
Generic Name
Brand
FDA Rec Max
Name®
per day
Aripiprazole
Abilify#
30 mg
Loxapine
Clozapine
Iloperidone
Ziprasidone
Adasuve
Clozaril
Fanapt
Geodon
Paliperidone
FDA Approved for
Schizophrenia
Mania/Bipolar
10 mg (Inhaled)
900 mg
24 mg
80 mg
Adol (13-17)
Adults
Adults- Agitation
Adults
Adults
Adults
Child & Adol (10-17);
Adults
Adults-Agitation
No
Adults
Adults
Invega
12 mg
Adults
Adults
Latuda
Lurasidone
160 mgSchizophrenia
120 mg-BPD
Depression
Adults
Adults (Bipolar
Depression only)
Risperidone
Risperdal#
8 mg
Adol (13-17)
Adults
Child & Adol (10-17);
Adults
Risperidone
Risperdal Consta*
50 mg/2 wks
Adults
Adults
Asenapine
Saphris
20 mg
Adults
Adults
Quetiapine
Seroquel
800 mg
Olanzapine
Zyprexa
20 mg
Adol (13-17);
Adults
Adol (13-17);
Adults
Child & Adol (10-17);
Adults
Adol (13-17);
Adults
# Also approved for use in children with Autistic Spectrum Disorder
* Long acting injection
SFBHN Psychotropic Medications Training 2014
Generic Name
Brand Name®
FDA Max per day
FDA Approved for
Schizophrenia
Child & Adol (3-17)
Mania/Bipolar
Haloperidal
Haldol◄
60 mg
Haloperidal
Haldol Decanoate*
300 mg/mo
Loxapine
Loxitane
250 mg
Thioridazine
Mellaril
800 mg
Thiothixene
Navane
60 mg
Pimozide
Orap ◄
No current brand
name exists
10 mg
No
No
40 mg
Adults
No
Fluphenazine
Prolixin Decanoate*
75 mg/2 wks
Adults
No
Trifluoperazine
Stelazine
80 mg
Chlorprmazine
Thorazine
2,000 mg
Fluphenazine
Perphenazine
Trilafon
◄ Approved for use in Tourette's Disorder
64 mg
* Long acting injection
Adults
Adults
No
Child & Adol (12-17)
Adults
Adults
Adults
Child & Adol (6-17)
Adults
Child & Adol (1-17)
Adults
No
No
Child & Adol (12-17)
Adults
No
No
No
No
No
SFBHN Psychotropic Medications Training 2014
Mood Stabilizers
SFBHN
Psychotropic Medication Training
Psychotropic Medications Training 2014

Mood stabilizers are medications used to treat bipolar
disorder with or without an antipsychotic.

Many antiepileptic medications (medicines for seizures)
can work as mood stabilizers.

Interventions for bipolar disorder are not necessarily
directed at “curing” the disorder but at optimally managing
it over time. The outcome is better when treatment is
continuous rather than “on and off” over time.
Psychotropic Medications Training 2014
Generic Name
Brand Name®
FDA Max per day
FDA Approved for
Bipolar Disorder
Divalproex/Valproic Acid
Depakote/Depakene*
60 mg / kg
Adults
Lithium
Eskalith / Lithobid*
1,800 mg
Adults
Lamotrigine
Lamictal
0.15-3.0 mg / kg
Adults
Gabapentin
Neurontin
1,800 mg
No
Carbamazapine
Tegretol / Equetro*
1,000 mg children;
1,200 mg adults
Adults
Topiramate
Topamax
5-9 mg / kg
No
Oxcarbazapine
Trileptal
1,800 mg
No
Psychotropic Medications Training 2014









Excessive thirst
Frequent urination
Nausea
Fine hand tremor
Muscles twitches
Acne
Itching, rash
EKG changes
Weight gain.
O
Psychotropic Medications Training 2014
Rare, unexpected, serious









Blackouts
Loss of coordination
Seizures
Slurred speech
Fast, slow, irregular, or pounding heartbeat.
Hallucinations
Changes in vision
Swelling of the eyes, face, lips, tongue, throat, hands, feet,
ankles, or lower legs.
Hypothyroidism.
Psychotropic Medications Training 2014











Changes in weight
Nausea
Stomach pain
Vomiting
Anorexia
Changes in appetite.
Vomiting
Diarrhea
Constipation
Skin rash
Increased suicidal thoughts and behaviors.
Rare, unexpected, serious
 Liver or pancreatic damage
 Polycystic ovarian syndrome (PCOS).
Psychotropic Medications Training 2014








Headaches
Dizziness
Diarrhea
Rash
Pruritus (itchiness)
Negative mood adverse reactions
Sleep changes
Increased suicidal thoughts and behaviors.
Rare, unexpected, serious

Liver or pancreatic damage

Steven Johnson Syndrome: A serious, potentially fatal allergic reaction
that leads to a skin rash and sores in the mouth.
REMEMBER: If a consumer develops a rash while taking Lamotrigine
(Lamictal) immediately contact the doctor.
Psychotropic Medications Training 2014

Mood stabilizers may effect the metabolism, liver,
kidneys, and thyroid.

Consumers taking Valproic acid / divalproex sodium
(Depakote), Lithium or Carbamazepine
(Tegretol/Equetro) should have routine blood work to
make sure the dose is safe and effective. Levels are
usually checked in the morning before the medication is
given to the consumer.
Psychotropic Medications Training 2014
The FDA has issued a warning for all of the mood stabilizers
listed previously EXCEPT lithium.
 This warning alerts people to the “increased risk of suicidal
thinking and behavior…”

REMEMBER: Consumers taking any mood stabilizer (except
lithium) should be monitored for new or worsened suicidal
thoughts and behaviors. Talk to the doctor or prescriber if this
happens.
Psychotropic Medications Training 2014
Caution should be exercised when…
 Consumers with pre-existing medical problems are
prescribed a mood stabilizer in which there may be an
interaction.
 Examples:
 lithium in persons with renal, cardiovascular or thyroid
problems
 divalproex (Depakote) in persons with liver problems
 topiramate (Topamax) in consumers with glaucoma.
Psychotropic Medications Training 2014

Category C: No adequate and well-controlled studies in
humans to determine the effect of the SSRI on the fetus.
 Lamotrigine (Lamictal)
 Gabapentin (Neurontin)
 Oxcarbazepine (Trileptal)

Category D: There is positive evidence of human fetal risk
based on adverse reaction data from investigational or
marketing experience or studies in humans, but potential
benefits may warrant use of the drug in pregnant women
despite potential risks.
 Lithium (Eskalith, Lithobid)
 Valproate/divalproex (Depakote)
 Topiramate (Topamax)
 Carbamazepine (Tegretol)
Psychotropic Meds Training 2014
Generic Name
Brand Name®
FDA Max per day
FDA Approved for
Bipolar Disorder
Divalproex/Valproic Acid
Depakote/Depakene*
60 mg / kg
Adults
Lithium
Eskalith / Lithobid*
1,800 mg
Adults
Lamotrigine
Lamictal
0.15-3.0 mg / kg
Adults
Gabapentin
Neurontin
1,800 mg
No
Carbamazapine
Tegretol / Equetro*
1,000 mg children;
1,200 mg adults
Adults
Topiramate
Topamax
5-9 mg / kg
No
Oxcarbazapine
Trileptal
1,800 mg
No
SFBHN Psychotropic Medications Training 2014
Anxiolytics & Other
Anti-Anxiety
Medications
SFBHN
Psychotropic Medications Training
Psychotropic Medications Training 2014
Generic Name
Brand Name®
FDA Max per day
FDA Approved
for Anxiety
Lorazepam
Ativan
10 mg
Adults
Buspirone
Buspar *
60 mg
Adults
Clonazepam
Klonopin
4 mg
Adults
Chlordiazepoxide
Librium
300 mg (IV/IM) ◄
Adults
Diazepam
Valium
40 mg
Adults
Alprazolam
Xanax
6 mg
Adults
SFBHN Psychotropic Medications Training 2014
Anxiolytics or anti-anxiety medications and antidepressants are
the most commonly used medications for anxiety disorders.
 Benzodiazepines (BZs) are a group of anxiolytic medications
that work differently than antidepressant medications:
 BZs generally start working more quickly.

 BZs
help improve situational anxiety but are less effective in
preventing or maintaining anxiety under control.
 The
effects of BZs usually do not last for a full day.
 BZs
are classified as controlled substances (Schedule IV).
 BZs
can result in dependence.
Psychotropic Medications Training 2014
What does it mean that benzodiazepines are controlled
substances by DEA (Schedule IV)?:
 Can be written with refills if appropriate
 Can be called in or faxed to the pharmacy
 Potential for abuse.
Psychotropic Medications Training 2014
Examples of Benzodiazepines (DEA Schedule IV controlled
substances):





Lorazepam:
Clonazepam:
Chlordiazepoxide:
Diazepam:
Alprazolam:
Ativan®
Klonopin®
Librium®
Valium®
Xanax®
Psychotropic Medications Training 2014
Buspirone (Buspar) is an anti-anxiety medication that is not a
benzodiazepine and:




Unlike benzodiazepines typically takes at least two
weeks to begin working.
Usually should be taken 2 – 3 times per day.
Is not classified as a controlled substance.
Has little scientific support for its use in children and
adolescents.
Psychotropic Medications Training 2014












Tiredness
Drowsiness
Dizziness
Unsteadiness when walking
Upset stomach
Blurred vision
Headache
Confusion
Memory problems
Nightmares
Depression
Increased suicidal thoughts and behaviors (clonazepam/Klonopin,
clorazepate/Tranxene).
Psychotropic Medications Training 2014
Rare, unexpected, serious






Respiratory depression (Dose dependent, with more severe
effects occurring with high doses).
Disinhibition
Hypomania in persons with depression
Blood dyscracias (abnormality of blood cells)
Liver problems
Seizures (withdrawal).
Psychotropic Medications Training 2014
Generic Name
Brand Name®
FDA Max per day
FDA Approved
for Anxiety
Lorazepam
Ativan
10 mg
Adults
Buspirone
Buspar *
60 mg
Adults
Clonazepam
Klonopin
4 mg
Adults
Chlordiazepoxide
Librium
300 mg (IV/IM) ◄
Adults
Diazepam
Valium
40 mg
Adults
Alprazolam
Xanax
6 mg
Adults
SFBHN Psychotropic Medications Training 2014
Misc Meds
SFBHN
Psychotropic Medications
Training
Psychotropic Medications Training 2014
Antihistamine medications, or antihistaminics, primary
indication is to treat allergies.
 These medicines are also contained in certain cold
remedies.
 Partly because of their relatively safe side effect profile,
sometimes these medications are used off-label for the
management of agitation and aggression.

Psychotropic Medications Training 2014









Drowsiness
Excitability (Especially in young children)
Dry mouth
Increased appetite
Itchiness
Headaches
Diarrhea
Constipation
Weight gain.
Rare, unexpected, serious
 Shakiness (Usually with higher doses)
 Seizures (Usually with higher doses)
 Dangerous drop in white blood cells.
Psychotropic Medications Training 2014
Generic Name
Brand Name®
FDA Max per day
FDA Approved for
Agitation & Insomnia
Diphenhydramine
Benadryl
100 mg
No
Hydroxyzine
Vistaril
400 mg
No
SFBHN Psychotropic Medications Training 2014
These medicines can be useful to treat certain side effects
secondary to antipsychotic use.
 Side effects that could be helped with these meds:
 Muscle stiffness/rigidity
 Muscle spasms of the back, neck and eyes
 Drooling

Psychotropic Medications Training 2014







Drowsiness
Excitability
Dry mouth
Blurry vision
Nausea/ upset stomach
Constipation
Weight gain.
Rare, unexpected, serious
 Confusion
 Inability to urinate
Psychotropic Medications Training 2014
Generic
Name
Brand
Name®
FDA Max
per day
FDA Approved
to help side effects of
Antipsychotics
Trihexyphenidyl
Artane
15 mg
Adults
Benztropine
Cogentin
6 mg
Adults
SFBHN Psychotropic Meds Training 2014
Psychotropic Medications Training 2014
What is true informed consent: A joint decision-making
process in which the individual, to the extent of his/her capacity,
is involved in discussions about his/her health care to improve
long-term outcomes and to foster trust and a better clincianconsumer relationship.
Engaging individuals helps:
 Empower them
 Encourages their active involvement in the decisions that
affect their lives
 Improves adherence
 Is more likely to have improved health outcomes.
Psychotropic Medications Training 2014
Continuous process:
 With the individual
 Family, caretakers or other important people involved
are the mediators.
 Information must be presented at age, intellectually and
developmentally appropriate level and language


There is no substitute for informed individuals.
Psychotropic Medications Training 2014







What is the name of the medicine? Is it also called by other names?
What do we know about how it helps other individuals who have a
similar condition?
How will the medicine help me? How long before I see if I get
better? When will it work?
What are the side effects or reactions which commonly can happen
with this medication?
Can I get addicted to this medicine? Can it be abused?
What is the recommended dosage or amount to take? How many
times a day do I take the medicine?
Are there any blood or other tests (e.g. heart tests, blood test, etc.)
which need to be done before I begin taking the medicine? Will
any tests need to be done while I take the medicine?
Psychotropic Medications Training 2014

Will a psychiatrist or other prescriber be checking to see how I am
doing with my medicine and make changes if needed? How often
will I go for appointments and who will do it?

Are there interactions or bad reactions between this medicine and
other medicines (prescription and/or over-the-counter) I am
taking?

Are there any activities that I should avoid while taking the
medicine? Should I take any special care for other activities?

How long will I need to take this medicine? How will the decision
be made to stop this medicine?

What do I do if a problem comes up (e.g. if I become sick, doses
are missed, or if I get side effects or bad reactions)?
Psychotropic Medications Training 2014
Monitoring for
Possible Side Effects or
To See if the Psychotropic Medication is Helping
Psychotropic Medications Training 2014
Monitoring for possible side effects or see if the psychotropic
medication is helping:

Use common sense!

It may sound basic – Always know if a child is being
prescribed medications.

Understand what the specific medication is supposed to help
with.

You need to know what the medicine is supposed to be
doing to be able to monitor if it is helping.
Psychotropic Medications Training 2014



Obtain regular feedback from the caregiver or any other
person involved in the child’s life, such as the child’s teacher
and/or other school personnel. Examples include:
 Has the child shown any changes?
 Is the child even taking the medication?
Ask the child how they are feeling – both physically and
emotionally.
Remember if not sure - Discuss with a supervisor.
Psychotropic Medications Training 2014
Psychotropic Medications Training 2014

Use common sense!

Report concerns or questions of possible side effects to the
child’s physician.
 This may require some persistence.
 Insist on a call back.
 Make yourself available for a call back.
 Schedule a new appointment if needed.
Psychotropic Medications Training 2014


As with all medical issues, if an emergency is suspected
call 911 or arrange for the child to go to the nearest
emergency department.
If you are not sure what to do = ACT!
 Discuss with a supervisor.
 Call the doctor.
Psychotropic Medications Training 2014
Clinicians should be aware:

Was an evaluation completed before initiating medication
treatment?

Has the prescriber provided feedback about the diagnosis
and educated the individual (and possibly family and
others) regarding the individual’s disorder and the treatment
and monitoring plan?

Has the individual provided consent before initiating
medication treatment and at important points during
treatment?
Psychotropic Medications Training 2014

Has the individual been engaged in the process?

Has the child provided assent (if appropriate)?

Has the assent and consent discussion focused on the risk and
benefits of the proposed and alternative treatments?

Have I reported concerns or questions of possible side effects
to the individual’s physician?
Psychotropic Medications Training 2014
Assisting Consumers who are being prescribed psychotropic meds:

Use common sense!

It may sound basic – Always know if a consumer is being
prescribed medications.

Understand what the specific medication is supposed to help
with.

You need to know what the medicine is supposed to be doing
to be able to monitor if it is helping.
Psychotropic Medications Training 2014



Obtain regular feedback from the consumer and any other
person involved in the consumer’s life (as appropriate).
Examples include:
 Has the consumer shown any changes?
 Is the consumer even taking the medication?
Ask the consumer how they are feeling – both physically and
emotionally.
Remember if not sure – Consult with the prescriber; discuss
with a supervisor.
Psychotropic Medications Training 2014

Use common sense!

Can it wait???

Encourage the consumer to contact the prescriber with
concerns or questions:


This may require some persistence.

Insist on a call back.

Make themselves available for a call back.

Schedule a new appointment if needed.
Consider reporting directly to the prescriber concerns or
questions of possible side effects.
Psychotropic Medications Training 2014


As with all medical issues, if an emergency is suspected
call 911 or arrange for the consumer to go to the nearest
emergency department.
If you are not sure what to do = ACT!
 Discuss with a supervisor.
 Call the doctor.
Psychotropic Medications Training 2014

Medications can be an important part of treatment for
some emotional and behavioral disorders.

Psychotropic medications should only be used as one part
of a comprehensive treatment plan.

Ongoing evaluation and monitoring by a physician is
essential.

Each clinician is also an important part of the monitoring
process.

Informed decision making is important.
Psychotropic Medications Training 2014

APPROPRIATE use of medications is the key.

Taking too much or too little of a medication can have
undesired consequences!

It is very important to take medications as prescribed.

Consumers should never add or stop a medication
without consulting the prescribing doctor.
Psychotropic Medications Training 2014
Children are our future
We all share a responsibility for their welfare
Psychotropic Medications Training 2014