Medication & Adolescents:
Empowerment Through
Education
Angela Campbell, Pharm.D., MS, BCPP
Tawny Smith, Pharm.D., BCPP
Outline
• List common psychiatric conditions medications
may help with in children and adolescents
• Discuss specific psychotropic medication side
effects or warnings
• Discuss FDA approval for medications in children
and adolescents
• Understand medication-taking behaviors in
adolescents
• List tips for providing medication education to
adolescents
Using Psychiatric Medications in
Children & Adolescents
Medication Treatment of Psychiatric
Disorders in Children and Adolescents
• What psychiatric conditions may be treated with
medications?
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Depression
ADHD
Anxiety disorders
Bipolar Disorder
Psychosis (Schizophrenia, Schizoaffective disorder, bipolar disorder
with psychotic features, major depression with psychosis)
PTSD
OCD
Irritability associated with autism
Aggression when related to a psychiatric disorder
Symptoms & Diagnosis
• In mental health, many diagnoses can have
the same symptoms
– Irritability: depression, bipolar disorder, substance
abuse, autism
– Aggression: bipolar disorder, ADHD, conduct
disorder, disruptive behavior disorder,
schizophrenia
– Depression: major depression, bipolar disorder,
schizophrenia
What is the relationship between
diagnosis and medications?
• There majority of psychotropic medications
are used to treat more than one diagnosis
– Antidepressants: depression, anxiety, OCD,
PTSD, eating disorders
– Antipsychotic medications: bipolar disorder,
schizophrenia, schizoaffective disorder, irritability
associated with autism, major depression (to
augment antidepressant effects)
Possible Side Effects of
Psychiatric Medications
Stimulants
• Examples:
– Amphetamine salts
• Adderall®/Adderall XR®
– Methylphenidate
• Ritalin®/Concerta®/Daytrana®
– Dexmethylphenidate
• Focalin®/Focalin XR®
Stimulants:
Potential Side Effects
• Most common side effect is decreased
appetite
• Small increases in heart rate and blood
pressure may occur, but are not usually
clinically significant
• No increased risk of serious cardiac events
– Use caution in people with existing heart problems
• Structural abnormalities (i.e., coronary artery abnormalities,
subaortic stenosis)
• Chest pain, irregular heart beat, high blood pressure, or
unexplained lightheadedness/fainting
Antidepressants
• Examples:
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Fluoxetine/Prozac®
Sertraline/Zoloft®
Paroxetine/Paxil®/PaxilCR®
Citalopram/Celexa®
Escitalopram/Lexapro®
Fluvoxamine/Luvox®
Venlafaxine/Effexor®/
EffexorXR®
– Duloxetine/Cymbalta®
– Bupropion/Wellbutrin®/
WellbutrinSR®/ WellbutrinXL®
– Amitriptyline/Elavil®
– Nortriptyline/Pamelor®/
Aventyl®
– Clomipramine/Anafranil®
– Doxepin/Sinequan®
– Imipramine/Tofranil®
Medications in this column typically used
infrequently in children and adolescents
Antidepressants:
Potential Side Effects
• Commonly causes an increase in anxiety for the first
7-10 days of treatment
– After this time, begins to help with anxiety
• Monitor closely for new-onset or worsening suicidal
thoughts or actions (FDA black box warning)
– Particularly during first two weeks of antidepressant
treatment
– Increased irritability, aggression, worsening depression,
anxiety, decreased need for sleep, or impulsivity could
indicate a switch to mania or worsening suicidality
Antidepressants
• The majority of studies have found that
antidepressants have a protective effect against
suicide
• Benefits of antidepressants appear to be greater
than the risk of suicidal ideation/suicide
Antidepressants
• How should the FDA warning be interpreted?
– Increased risk of suicidality possible during first few weeks of
treatment with antidepressants
– Assessment, careful and accurate diagnosis, and monitoring
are of the utmost importance
– Nonmedication treatment alternatives should be tried first, if
possible
– Antidepressants should be used in children and adolescents
who require medication treatment for depression
– Initial assessment of suicidality is critical, as is ongoing
monitoring for suicidal thoughts/plans
– Know what symptoms to watch for and be aware of
Behavior changes that indicate young
person needs help
• Sudden drop in grades
• Changes in friends or personality
• Constant thoughts and fears about their
personal safety or safety of family members
• Does not want to go to school
• New or frequent complaints of headache,
stomach aches, and other sicknesses
• Trouble sleeping or nightmares
Behavior changes that indicate young
person needs help (continued)
• Prolonged feelings of sadness and loneliness
• Doesn’t care about favorite activities or is “too
tired to play”
• Feels angry, getting into fights
• Trouble sitting still or concentrating
• Running away
• Noticeable weight loss or gain
• Talks about death/suicide
Antipsychotics
• Examples:
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Aripiprazole/Abilify®
Asenapine/Saphris®
Clozapine/Clozaril®
Iloperidone/Fanapt®
Lurasidone/Latuda®
Olanzapine/Zyprexa®
Paliperidone/Invega®
Quetiapine/Seroquel®
Risperidone/Risperdal®
Ziprasidone/Geodon®
– Chlorpromazine/
Thorazine®
– Fluphenazine/Prolixin®
– Haloperidol/Haldol®
– Loxapine/Loxitane®
– Molindone/Moban®
– Perphenazine/Trilafon®
– Trifluoperazine/
Stelazine®
– Thioridazine/Mellaril®
– Thiothixene/Navane®
Antipsychotics:
Potential Side Effects
• Possibility for increased appetite and weight
gain
– Talk with doctor quickly if weight gain occurs;
easier to address early on
• Possibility to cause extrapyramidal side
effects (EPS)
– Sudden onset of very stiff muscles/spasms
– Restlessness, inability to sit still
– Rigid joints, pill-rolling tremor, stiff walk
Antipsychotics:
Potential Side Effects
• Possibility to cause an increase in prolactin
levels
– Change in menstrual cycle, absence of menstrual
cycle, breast growth (males or females), lactation
(males or females)
– Not a medical emergency, but let your doctor
know!
• Doctor may need to adjust dose or switch medications
Lithium
• Possible side effects: stomach upset,
diarrhea, ↑ appetite, weight gain, less clear
thinking, feeling tired, shakiness, acne
• Laboratory monitoring is very important!
– Can affect the thyroid and kidneys
– Can monitor drug levels
• Many things can increase lithium levels
– Low salt diet, dehydration, NSAIDs (i.e.,
ibuprofen, naproxen), some blood pressure
medications
®
Depakote
(divalproex, valproic
acid)
• Possible side effects: shakiness, weight gain,
stomach upset/nausea, dizziness, hair loss,
• Laboratory monitoring is important!
– Can affect the liver, pancreas
– Can cause decreased platelets and increase
ammonia
– Can monitor drug levels
Tegretol ® (carbamazepine)
• Possible side effects: feeling tired, stomach
upset, thinking not as clearly, dizziness, rash
• Laboratory monitoring is important!
– Can cause unsafe blood cell count problems
(rare)
– Can cause low blood sodium levels
– Can monitor drug levels
• Interacts with many other medications
Lamictal® (lamotrigine)
• Possible side effects: stomach upset,
headache, skin rashes, dizziness, feeling tired
– If rash develops, call MD right away, and stop
taking lamotrigine
– Rash can worsen and become very serious
requiring medical attention, especially if person
continues taking lamotrigine
The Food and Drug Administration (FDA)
and Psychotropic Medications in Children
& Adolescents
The Food and Drug Administration and
Medications in Children and Adolescents
• In order for a medication to gain “FDA approval,” the
company who makes a medication must conduct a study to
show it is safe and effective
• Many psychotropic medications do not have FDA approval in
children and adolescents
– Studies may not be conducted in pediatric patients for many reasons
• The FDA does not regulate physician or other healthcare
provider prescribing of medications
– The FDA states it “does not limit the manner in which a practitioner
may prescribe an approved drug”
– Studies and expert clinical opinion often support the “off label” use of
medications
Psychotropic Medication Utilization Parameters in Foster
Children and Youth, DFPS 2013
The Food and Drug Administration and
Medications in Children and Adolescents
• Many medications are used “off-label” in children
and adolescents
• Often, there are many studies to support that a
medication is safe and effective, even if there is
not FDA approval
• Discuss with your doctor if you have concerns
– Ask if there is evidence to support the use of that
medication in children or adolescents (It is okay to
ask this question!)
Medication-taking Behaviors in
Adolescents
Adolescents and Medications
• “We should not assume that youth have understood
their illness, made sense of their medication
treatment, or have adhered to the regimen as
adults.”
• “Health research has demonstrated that adolescents
draw on personal perceptions, beliefs, and
meanings in their experience of medical
interventions.”
– Example: youth with asthma may modify medical advice
about asthma treatment when they believe their
knowledge supersedes that of doctor
Floersch et al. Adolescent Experience of Psychotropic Treatment.
Trancult Psychiatry 2009; 46: 157-179
Adolescents [and Medications]
• May assert autonomy by resisting standard treatments
• May not adhere to prescribed medications when they do
not feel like taking medication
• May choose not to take their medications when they feel
“healthy”
• May stop medications that prevent progression of illness
or prevent relapse of illness when the medication does
not provide the reinforcement of feeling well or
immediate relief of physical symptoms
• May stop taking medications because they feel well or
no longer feel the medication is needed
Floersch et al. Adolescent Experience of Psychotropic Treatment.
Trancult Psychiatry 2009; 46: 157-179
Adolescents and Medications
• Studies have shown:
– Adolescents may discontinue asthma medication when they do
not recognize symptoms of the illness in themselves, such as
shortness of breath (van Es et al. 1998)
– Adolescents with chronic asthma may discontinue medications
when they feel the medication is ineffective or feel they don’t
have the illness (Buston & Wood 1999; van Es et al. 1998)
– Adolescents with diabetes may resist treatment for diabetes or
may not adhere to prescribed treatment when they don’t feel
like taking medication (Adams et al. 1997; Kyngas & Hentinen
1995)
– HIV positive adolescents may avoid taking antiretroviral
medications when they feel healthy (Pugatch et al. 2002)
Floersch et al. Adolescent Experience of Psychotropic Treatment.
Trancult Psychiatry 2009; 46: 157-179
Adolescents and Medications
• Adolescents respond to medication treatment in
profoundly different and personal ways that
influence adherence and treatment effectiveness
• The theme of expectation and hope seems
particularly important in adolescent medication
taking behavior
• So, how can you encourage or influence
adolescents to take medications?
Floersch et al. Adolescent Experience of Psychotropic Treatment.
Trancult Psychiatry 2009; 46: 157-179
Providing Medication Education to
Adolescents
Medication Education:
Empowering Adolescents
• What to discuss with adolescents and their
families about their treatment:
– De-stigmatize the experience of mental illness
– Give education about the origins, time course,
and treatment options for mental illness
– Empower the child/family to get the help they
need and to take charge/control of their own
health and well-being
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Medication Education:
Empowering Adolescents
• Psychiatric medications are challenging because there is
often a long delay before the medication effect “kicks in”
– Aspirin for a headache → begins to work in about 30
minutes
– Fluoxetine/Prozac™ for depression → begins to work in
about 3-6 weeks
• This is a long time to wait to feel better!!
• Important to remind and educate teenagers of this, and
to provide encouragement/motivation to continue taking
the medication until it begins to help with symptoms
– Keep the endpoint in mind!
Things adolescents want to know
about mental illness:
• How/why mental illness occurs
– Typically occurs due to imbalances of brain
chemicals, called neurotransmitters (too
much or too little)
– Often, genetics are involved
– Stress or trauma is often implicated
– Sometimes occurs randomly
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Things adolescents want to know
about medications:
• How psychiatric medications work:
– By helping to regulate brain chemicals
(neurotransmitters) which send signals to different
parts of the brain and body
– May help normalize the levels of these chemicals
in the brain which in turn, improves symptoms of
mental illness
– Must take the medication CONSISTENTLY (every
day) for it to help
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Things adolescents want to know
about medications:
• Specifically how the medication will help
them:
– improved mood
– better concentration
– more normal sleep
– more normal appetite
– greater interest in activities
– more energy
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Things adolescents want to know
about medications:
• Will medication change who I am?:
– Medication will not change who you are or make
you different from other young people.
– It will help you get back to the way you were
before you became ill so that you feel like yourself
again.
– Taking medication is not much different than
wearing glasses or braces – it’s only a tool to help
you get well or feel better.
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Things adolescents want to know
about medications:
• Are psychiatric medications addicting? Will I
become dependent on them?:
– Definition of addiction: compulsive need for and use of a habitforming substance (as heroin, nicotine, or alcohol) characterized by
tolerance and by well-defined physiological symptoms upon
withdrawal; broadly : persistent compulsive use of a substance known
by the user to be harmful
– Definition of dependence: the quality or state of being
dependent; especially : the quality or state of being influenced or
determined by or subject to another
http://www.merriam-webster.com/dictionary
Things adolescents want to know
about medications:
• Are psychiatric medications addicting? Will I
become dependent on them? (continued):
– Most psychiatric medications are not addicting and do
not cause dependence
• Antidepressants, antipsychotics, mood stabilizers, stimulants for
ADHD
– Some psychiatric medications have the possibility to be
addicting. Generally these are only prescribed for short
periods of time to limit the potential for addiction or
dependence.
• Benzodiazepines (lorazepam, clonazepam, alprazolam, etc.)
• Some sleep medications (zolpidem/Ambien®,
eszopiclone/Lunesta®, etc.)
Things adolescents want to know
about medications:
• Are psychiatric medications addicting? Will I
become dependent on them? (continued):
– Psychotropic medications get a “bad rap” for being
addictive because they do have to be TAKEN to work or
cause an effect (just like any medication). If they are not
taken, relapse can occur.
– Medications control symptoms and keep illness stable, but
must be taken every day, usually long-term
– Currently there is no “cure” for mental illness
– Similar to having diabetes, asthma, or thyroid illness –
need daily medication to manage/control mental illness
Things adolescents want to know
about medications:
• How long will I have to take the medication?:
– If the medication is helpful and you have no
problems with it, you will probably need to take
the medications for a number of months, even
after you feel better to make sure the
symptoms are better.
– In some cases (depending on which illness),
medications may need to be taken for life.
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Things adolescents want to know
about medications:
• Are psychiatric medications safe to take longterm/for life?
– YES!
– Most medications have long studies (several
years in duration) conducted to ensure safety with
long-term use
– There have been medication treatments for
mental illness since the late 1950’s/early 1960’s
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Things adolescents want to know
about medications:
• Are psychiatric medications safe to take longterm/for life? (continued)
– Usually side effects (unwanted effects) of meds occur
early on in treatment, so possible to adjust or switch
medications in order to find the right “one”
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Medication Education:
Empowering Adolescents
• What is my role in taking medications for mental illness?:
– Learn what medication you take, how much to take, and what it
is for
– It is your responsibility to take medication in the right amount at
the right time (may need help from parents/caregiver!)
– Don’t take other medications without asking your doctor first,
even over-the-counter medications
– Never use alcohol or drugs while taking medication. It can be
dangerous or deadly.
– Talk with your doctor about any problems you experience while
taking medications.
– Even if you feel okay or good, take your medication every day
Guidelines for Adolescent Depression in Primary Care 2010
http://www.glad-pc.org/
Medication Education:
Empowering Adolescents
• Adolescents need to know whether compliance with
medications is important (It is!) and the potential
consequences of noncompliance
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Medication may not work
Recurrence of illness or symptoms
Potential for hospitalization
Medication may not work as quickly/help as much after
a relapse occurs
– Stress that psychiatric medication has to be taken longterm (EVERY DAY)
Medication Education:
Empowering Adolescents
• Encourage the adolescent to self-evaluate and
make notes of positive and negative aspects of
taking the medication
– Mood diary
• Discuss these with the doctor
• May remind adolescent often (daily if needed)
about the link between symptoms, behaviors,
and feelings and the rationale for taking
medications
Strategies for Providing Medication
Education to Adolescents
Medication Education:
Teaching Adolescents
• Important to make medication information
RELEVANT to adolescents
– Keep it real
• Give realistic information about time medication typically
takes to work
• Give realistic expectations of response to medications or
how well medication will potentially work
• Give accurate but not overwhelming information about side
effects
– Give information about common side effects
– Give information about “medical emergency” side effects and what to
do if they occur (STRESS THAT THESE ARE RARE!)
Medication Education:
Teaching Adolescents
• Make YOURSELF relevant (Why should they
listen to you?)
– Helps to stay (at least a little) up-to-date with
current events in adolescent pop culture
– Make the information interesting
– Make sure you know what you’re talking about
• Teens respond to knowledgeable and relevant
information
• If you sound like (and do!) know what you’re talking
about, they typically tune in
Medication Education:
Teaching Adolescents
• Make the information and delivery of the
information interesting
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Energetic delivery
Use examples
Use stories
Use humor
Work in current events related to your educational
topic
• Substance abuse example: Lil Wayne recently hospitalized
when he had a seizure after ingesting “sizzurp/purple drank”
(i.e., phenergan with codeine cough syrup)
Learning Tools
• Jeopardy-type board games
• Educational reading material or websites
– http://www.nami.org/Template.cfm?Section=By_Illness
– http://www.glad-pc.org/
– http://www.nimh.nih.gov/health/topics/child-andadolescent-mental-health/index.shtml
– http://www.hhs.gov/ash/oah/adolescent-healthtopics/mental-health/
– http://www.psychiatry.org/teens
– http://www.who.int/mental_health/prevention/childado/en/
Jeopardy Board Game
Jeopardy Board Game
Questions?