Appendix D Psychiatric Diagnoses & Treatment

Transcription

1 Appendix D Psychiatric Diagnoses & Treatment The following is basic information on the major mental disorders and the medications generally used to treat each type of major mental illness. Each medical condition is discussed with a table of its medications of choice by brand and generic name. The possible benefits of the medication and some of it s more common or prominent side effects is also presented. The purpose of this information is to alert you to the importance of reviewing recommended medications and treatments. This will better enable you to be an informed Guardian Advocate who is able to stand in another individual s shoes in making major decisions on that individual s behalf. Concepts How will you look at a planned medication trial - probable usefulness versus possible harm? When the individual you are representing is discharged, will he or she continue to use the medications properly? Do you know if medication abuse, or suicide attempts with medications has previously been a problem? This (above) information will be very important later in the person s treatment plan. Is it important now? General Drug Interactions Some of the major drug interactions will be presented. To list all the known drug interactions is impossible. Further, the Guardian Advocate is cautioned that new drugs and new interactions are discovered every day. Not only are new prescription drug interactions possible, but new over-the-counter drug interactions as well. These over-the-counter drug interactions can be as serious a threat to the person you are representing as mixing two prescription medications. A person who recognizes this fact and seeks the advice of a pharmacologist or health care provider will avoid most drug interactions. One common drug interaction is with alcohol. Alcohol can, above all other interactions, produce liver damage. The danger to the liver is not rare, but alcohol has negative effects on mental well-being and has the potential to ruin a period of recovery or remission of symptoms. A person with mental illness should avoid alcohol because its effects are so harmful. New drug Interactions are discovered every day. Each person reacts in different ways. Allergies vs. Side Effects Allergies are the body s reaction to what it regards as foreign stimuli (allergen) that cause reaction. Histamine release is at the root of many unpleasant body events in such an allergic reaction. A few of these are listed below. Runny nose and watery eyes - This is the classic hay fever. The histamine release in the nose and eye tissues can be triggered by allergen particles in the air that come in contact with the nasal passages and eyes. Skin Rashes - Rashes can affect a small or large percentage of the body. Poison ivy oil, for example, causes histamine to be released. In response, blood vessels dilate, fluid is released, and a rash or swelling forms. Gastrointestinal Disturbances - Responding to eating something one is allergic to; histamine release in the Gl tract can cause nausea, vomiting, and/or diarrhea. Breathing Difficulties - This is the most serious reaction. The histamine release causes inflammation of the airways which creates difficulty in breathing. The inflammation can be severe enough to totally close the airways. At this point the allergic reaction is truly life threatening. It is possible to have any or all of these reactions to a medication. It is important to clarify the difference between these allergic reactions and side effects. Most symptoms that a person may describe as allergic reactions are often known side effects. Most individuals are relieved to know the reaction is not a rare, deadly allergic response and that it is expected and treatable. An informed reassured person tolerates known side effects better and is more compliant. Guardian Advocate Training and Resource Manual 2006 Appendix D - 1

2 Another advantage of educating the person is that this person can knowledgeably participate with the physician in choosing a medication. If a medication has caused intolerable side effects, the doctor must decide whether it is a side effect or an allergic reaction. An educated person can give the doctor valuable information. History of an allergic reaction might eliminate a whole class of medications for possible use in the individual. However a serious side effect may only eliminate the specific offending drug from consideration. In treating severe mental illnesses, the person should have as many reasonable medication options to choose from as possible to optimize care. Treatment Participation Here are some questions that you might find useful to ask when new medications are being prescribed: What will this medication do for the person I am representing? Why is this particular medication being considered? What are the side effects? How long do the side effects last? Are any of these side effects dangerous? Are they treatable or non-reversible? Is there another equally effective medicine that does not have these side effects? Has it been tried for this disorder before? Are any drug interactions listed in this individual s chart? Is any follow-up monitoring needed? (This is usually in the form of blood tests to check level of the drug, liver function, kidney function or hematological status.) The Importance of Medication Compliance All of these medications have the potential of producing dramatic significant benefits for an individual. If the person does not take the medication, for whatever reason, its benefit will not be felt. Non-compliance with medication is the major reason for re-admissions to crisis stabilization units and hospitals. A person s decompensation (returning to the previous unmedicated state of illness) carries a high cost to the person in the form of psychological pain, frustration, and worst case, death. It is also costly to society in the form of increased health care expense. Side effects are a major reason for medication noncompliance (e.g. failing to regularly follow the prescribed medication schedule necessary for the effectiveness of the medication). A sympathetic and supportive Guardian Advocate or family members can have a positive affect on a person s level of compliance with the medication schedule. A person who feels that his or her Guardian Advocate and treatment provider are concerned and care about unpleasant side effects feels better about sticking with the medication. It seems obvious that a person who is cared for by individuals uninvolved or not supportive of the person s feelings or goals is not going to tolerate unwanted side effects as well as a person having a sympathetic or supportive family or friends. Persons having to go it alone often become discouraged, lose motivation to become less ill; and stop taking their medication regularly. It certainly is not out of the realm of possibility that if we care and take an active role in easing or preventing side effects that a person s level of medication compliance, as well as hopefulness and optimism about the course of treatment should increase. The second issue in improving medication compliance occurs when the person is stable and feels fine while taking medications. The danger occurs when the person has been discharged from the hospital and feels that he/ she is healed and no longer sees the need for taking the medication. Other chronic illnesses like hypertension and diabetes, for example require persons to take medication for the rest of their lives. Mental illness is also an illness that may require life-long medications. Similar chronic illnesses, like diabetes, do not have the negative social stigma that some mental illnesses do. Fortunately in modem society there is no longer any stigma in taking medications for diabetes. Sadly, however, too many people feel differently about medications taken to treat mental illnesses. This stigma, expressed even by family members may discourage the person from taking the needed medication. It is hopeful that some of the stigma can be eliminated each time this information is provided. For persons needing such medications the failure to sustain medication compliance is likely to cause repeated cycles of hospitalization with an accompanying lowering of mental abilities. Appendix D - 2 Guardian Advocate Training and Resource Manual 2006

3 Psychotherapeutic Medications The term Psychotherapeutic Medication refers to all medications used to treat brain disorders that result in primary disturbances in mental function. Depending on the effect of the drug, treatment medications may be lumped into various groups: Antipsychotics, Antidepressants, Mood Stabilizers, Hypnotics, and Antianxiety. Properly used, psychotherapeutic medications can cause rapid and significant improvement in the way the person feels and acts. However, psychotherapeutic medications can have negative effects. As a Guardian Advocate, one of your responsibilities will be to choose or agree to a course of treatment for a particular person. Consequently, you may need to give express and informed consent for the use of one or more of these medications. The doctor will explain the likely benefits, serious negative reactions, temporary and permanent side effects and risk associated with each proposed psychotherapeutic medication to the person and to you. You may ask questions of any kind about each medication. For the Guardian Advocate, the most basic part of medication treatment planning is providing substitute judgment. This is why the Guardian Advocate must understand the information well enough to make a logical decision about the planned medication and course of treatment. Medications and Disorders The following presents the most commonly used psychotherapeutic medications for each diagnosis: Schizophrenia, Mood Disorders (bipolar and depression), and Anxiety Disorders. Schizophrenia Schizophrenia, a medical condition of the brain, is a chronic disorder of both thought and mood. It interferes with the person s ability to maintain interpersonal relationships and to function in daily life. Anti-psychotic Medications Anti-psychotic medications are used to help control the distressing signs and symptoms suffered by an individual who has schizophrenia. Some examples include: Atypical or Second-Generation Clozapine Risperidone Olanzapine Quetiapine Ziprasidone Aripiprazole Chlorpromazine Thioridazine Haloperidol Perphenazine Fluphenazine Pimozide Thiothixene Molindone Loxapine Droperidol Clozaril Risperdal Zyprexa Seroquel Geodon Abilify Typical or First-generation Thorazine Mellaril Haldol Trilafon Prolixin Orap Navane Moban Loxitane Inapsine Common Side Effects of Anti-psychotics Common side effects of anti-psychotic medications may include: Drowsiness - This side effect does not always happen and it usually lessens with time. Drowsiness does prevent a person from being totally alert, which makes many parts of community life potentially dangerous. Urinary Retention or Hesitancy - The person may become quite uncomfortable with a full bladder. Dry Mouth, Drooling, and Constipation - These conditions are uncomfortable, but manageable. Many of the medications used for relieving mental illness have these side effects. Changes in Blood Pressure - Orthostatic Hypotension A neuroleptic side effect, felt as being dizzy or faint when standing up. Falling in a faint is rare. Normally, when someone stands or gets out of bed in the morning, a reflex vasoconstriction happens to maintain blood pressure. Neuroleptics may slow this reflex for a person. Guardian Advocate Training and Resource Manual 2006 Appendix D - 3

4 Alteration in Body Temperature - This side effect of neuroleptics is often overlooked. The neuroleptic drugs can upset the temperature regulating center in the brain. A person who is taking a neuroleptic may lose the ability to sweat even to the point of heat stroke. The staff and persons taking the medications should be very careful about this. Some people, especially the elderly, are more at risk for hypothermia, or lowered body temperature. Sensitivity to Sunlight - Thorazine is known to cause this, but it can happen with other antipsychotics. Some persons become much more sensitive to the sun, Persons with this side effect may feel the skin burning before the severe sunburn can be seen. Protective clothing or a good sun screen can prevent tine feeling and the burn. Abnormal Involuntary Movements - Akathesia - The person feels a compelling need to be in constant movement. A phenothiazine side effect, the person cannot sit still, and may pace, squirm, shuffle in place, tap the feet, drum the fingers, and more. The affected person may talk about an antsy feeling of restless. Akathesia is a possible side effect of the antipsychotics. Body Tremors, Slowed Movements, Postural Changes Parkinsonianism, a side effect of the phenothiazine or butyrophenone anti-psychotics, goes away when the medication is changed or the dosage is reduced. Blurred Vision - Generally a temporary side effect, follow-up is recommended. For people with narrow angle glaucoma, caution is recommended. Opaque deposits on the cornea and lens can occur with phenothiazines. Retinitis Pigmentosis can occur with Mellaril at doses greater than 800 mg a day. In most of these cases of blurred vision, an initial eye exam is routine practice and regular eye examinations are recommended in some cases. Sexual Dysfunction - This side effect is the most frequent reason given for no longer taking helpful medication. The doctor will try to eliminate the effect by lowering the dose or changing medications. A dose change may not eliminate this side effect. Everyone involved in the treatment issue individual, Guardian Advocate, and doctor may need to rethink therapeutic medications. Muscle Stiffness / Dystonia - a state of abnormal tonicity or prolonged tonic contractions. Dystonia can be frightening and very painful. Every muscle in a leg, for instance, may suddenly knot into hard cramps. Dystonia may also cause a person s tongue to stick out, or make the eyes move rapidly. The person is helpless to stop the muscle actions. Muscle Spasms Weight Gain Restlessness Adverse Reactions Possible from Antipsychotics Tardive Dyskinesia (TD) - is a movement disorder where there are uncontrolled facial movements and sometimes jerking or twisting movements of other body parts. This condition may develop after several years of taking antipsychotic medications. It occurs mostly in older adults. Tardive Dyskinesia affects 15 to 20 percent of people taking typical antipsychotic medications. The risk of developing Tardive Dyskinesia is lower for people taking the newer atypical antipsychotics. Tardive Dyskinesia can be treated, but not cured. Neuroleptic Malignant Syndrome (NMS) - is a rare, but very serious side effect. Signs to watch for are muscle stiffness that occurs over one to three days, a high fever, and confusion. If these symptoms occur, seek medical help immediately go to the emergency room if you cannot reach the doctor. Mood Disorders Mood disorders are a category of mental health problems that includes a disturbance in mood, usually deep sadness or indifference, excitement, or irritability. These include Bipolar Disorder (previously called Manic-Depressive disorder) and Major Depressive Disorder. Mood stabilizers are primarily used to treat bipolar disorder and to stabilize mood in other conditions. Antidepressants are used to treat major depressive disorders and severe depression in other conditions. Appendix D - 4 Guardian Advocate Training and Resource Manual 2006

5 Lithium carbonate Lithium citrate Mood Stabilizers Eskalith, Lithonate & Lithobid Cibalith-S Anti-Seizure Medications Divalproex sodium Depakote Lamotrigine Lamictal Carbamazepine Tegretol & Carbatrol Oxcarbazepine Trileptal Topiramate Topamax Gabapentin Neurontin Side Effects of Lithium Side effects of lithium may include: Nausea, stomach cramps, diarrhea, mild hand tremor, muscle weakness, dry mouth, thirst, frequent urination, trouble concentrating, acne, and lethargy are common, but usually disappear after the person s body becomes accustomed to the lithium dosage. Hand Tremors - Simultaneous treatment with some types of anti-depressants can worsen this tremor. Heavy tremors may indicate lithium toxicity. Renal Toxicity - Lithium can reduce the kidney s ability to concentrate urine in some people. It is important to monitor kidney function in all persons. Thyroid Effects - Lithium therapy can induce Hypothyroidism, causing weight gain, fatigue, low energy, and slowed mental function, which may be mistaken as being Lithium side effects. Thyroid function testing, diagnosis, and monitoring for this complication and thyroid supplementation can be added to the medication regimen. Cardiac effects - Many cardiac dysfunctions are possible during Lithium intoxication, Before starting any medication, a baseline ECG is done for future comparison. These cardiac effects can be life threatening. If preexisting cardiac disease is present, a consultation with a cardiologist is usually recommended. Lithium Toxicity - Lithium can produce serious toxic reactions when there is too little fluid in the blood, called Dehydration. Water pills (diuretics), caffeine, and alcohol deplete blood fluids. Other factors that can reduce the body s fluids and increase lithium levels are exercise with excessive sweating, fever, flu, diarrhea, vomiting, decrease in water intake, and slimming diets. A low sodium diet will increase Lithium levels because the kidneys need salt to function well. During Lithium therapy, the body must have enough salt and ten to twelve glasses of water every day to prevent the build up of lithium to toxic levels. Symptoms of Lithium toxicity may include diarrhea, vomiting, nausea, slurred speech, convulsions, confusion, drowsiness and severe trembling. The higher the level of lithium in the blood, the worse these symptoms become. The doctor should be notified immediately if these symptoms appear. Medications can change Lithium levels. Tetracycline increases lithium blood levels, many asthma aids and the new headache remedies can lower the lithium blood level. Antipsychotic drugs, frequently used with lithium, may increase the risk of toxicity. Side Effects of Anti-seizure Medications Depakote can cause drowsiness, upset stomach, diarrhea, dizziness, and tremors. Long term effects can include weight gain, hair thinning, and mild change in liver function tests. Other anti-seizure medications can cause drowsiness, irritability, nausea, rash, and clumsiness. Some drugs produce changes in emotions, memory, behavior, or affect learning. Occasionally, a drug will increase the number of seizures a person is having. The doctor should be notified if a prolonged fever, rash, severe sore throat, mouth ulcers, easy bruising, weakness, excessive fatigue, swollen glands, or lack of appetite occurs. Anti-Anxiety Medications Benzodiazepines are widely used to treat anxiety symptoms and sleep problems in adults and research shows some support for their use in children and youth. These medicines are subject to potential non-medical misuse. They can contribute to excessive sedation and intoxication, especially when combined with alcohol. Clonazepam Lorazepam Alprazolam Benzodiazepines Klonopin Ativan Xanax Guardian Advocate Training and Resource Manual 2006 Appendix D - 5

6 Side Effects of Benzodiazepines Benzodiazepines can cause dizziness, light-headedness, drowsiness, clumsiness, unsteadiness, and slurred speech. These problems usually go away as the body adjusts to the drug and do not require medical treatment unless they persist or they interfere with normal activities. Carbamazepine Divalproex sodium Tegretol Antimanic Medications Tegretol Depakote A medication that is useful for treating seizures and as a mood stabilizer. Information may be found in the Antiepileptic sections of most medication references. Side Effects of Tegretol Side effects of Tegretol may include: Dizziness and drowsiness are common. Blurred vision, constipation, dry mouth, nausea, aching joints and unsteadiness are rare and should lessen or disappear as an person gets used to the medication. Sodium level may also become low and need to be watched. Skin infections can be treated, but follow-up is required. Aplastic Anemia (destruction of bone marrow), appears to be very rare. Hemotological Problems - Early signs are fever, sore throat, mouth ulcers, and bruising. These can all be signs of leukopenia, (diminished number of white blood cells), aplastic anemia (destruction of bone marrow), or thrombocytopenia (diminished number of red blood cells). Hepatic Liver Complications - Baseline liver enzymes may be ordered. In same cases, a rare liver inflammation (Granulomatousa Hepatitis) may occur, Early in therapy, while the dose may continually need to be increased, liver functions may be altered, two other prescription drugs, erythromycin and isoniazid can elevate carbamazepine levels, as may Cimetidine / Tagamet. Liver function tests should be done at least yearly. Other Adverse Effects - color appearing In the eyes, extreme weakness, abnormal bleeding, and skin changes. Yellowing of the skin or eyes, and urinary changes. Depakote - Valproic Acid: Side Effects of Depakote Most often, a person beginning therapy with depakote will experience a dry mouth and a frequent need to urinate. Stomach and bowel upsets occur, drowsiness, lethargy, and dizziness are also common. Rare side effects may include a slight hand tremor, temporary hair loss, change in weight and constipation. Toxicity of Depakote to the liver and pancreas is well documented. Liver toxicity may initially present itself as facial edema, malaise, jaundice or vomiting. Depakote should be administered with caution in persons with preexisting liver or pancreas dysfunction. Liver function will be monitored every 6-12 months. Liver toxicity can result in coma and death. Depakote should never be taken during pregnancy. Depression Antidepressants are used in the treatment of depression, as well as other psychiatric disorders. There are four major classes of antidepressants: Selective Serotonin Reuptake Inhibitors (SSRIs) Fluoxetine Sertraline Paroxetine Fluvoxamne Citalopram Escitalopram Side Effects of SSRIs Prozac Zoloft Paxil Luvox Celexa Lexapro Side effects of Selective Serotonin Reuptake Inhibitors may include anxiety or nervousness, nausea and diarrhea, headache, insomnia, rash, slight weight loss, and decrease in sexual ability or desire. Appendix D - 6 Guardian Advocate Training and Resource Manual 2006

7 Other Newer Antidepressants Venlafaxine Duloxetine Bupropion Nefazodone Trazodone Effexor Cymbalta Wellbutrin Serzone Desyrel Tricyclic Antipressants (TCAs) Nortriptyline Desipramine Imipramine Clomipramine Amitriptyline Pamelor Nopramin Tofranil Anafranil Elavil Side Effects of Tricyclic Antidepressants Side effects of Tricyclic Antidepressants may include: Anticholinergic - dry mouth and constipation are very common; less often are mild hand tremors, blurred vision, and worsening of narrow-angle glaucoma. Sedation - Drowsiness or sedation can be a benefit to the depressed person who has insomnia. Orthostatic Hypertension - Drop in blood pressure upon standing up, feelings of dizziness or faintness; falling in a faint is rare. Seizures - Some of the TCA s may cause seizures in non-epileptic persons. Conductive / Cardiovascular Abnormalities - Increased heart rate; moderate risk of a bundle branch block which ultimately slows heart rate. These medications can be fatal for a person with existing heart problems. Before starting a person on a TCA, an ECG should be taken. Comparison of heart activity before and after administering the initial TCA will be possible. Anxiety, Insomnia, and Agitation -These are very common with the SSRI s and account for a large percentage of discontinuations. Drowsiness, fatigue, and weakness. Anxiety, increased heart beats. Restlessness and muscle twitches. Cognitive and memory difficulties. Nausea, constipation, urinary retention, and difficulty urinating. Weight gain. Increased sweating. Increased sensitivity to the sun. Decreased sexual ability or desire. Some of these side effects will disappear with the passage of time or with a decrease in the dosage. Monoamine Oxidase Inhibitors (MAOI s) Tranylcypromine Phenelzine Parnate Nardil Side Effects of MAOIs Dizziness, rapid heartbeat, loss of sexual interest, and food interaction Orthostatic Hypotension Dietary Restrictions - Foods that may be fatal include: ripened cheeses, fermented sausages, soy sauce, anchovies, pickled herring, broad beans, and red wine. Hypertensive Crisis - The heart rate increases and the blood vessels constrict, producing a dramatically high blood pressure. This can occur when MAOI s are taken with certain foods or drugs. This can be life threatening and is the major reason why MAOls are not used more often. The person must be alert to these drug and food interactions. MAOI treatment should be re-evaluated as an option if the person is unable to follow the necessary diet. MAOIs react with certain foods and alcoholic beverages, and some medications, to produce a severe reaction which often does not appear for several hours after taking the medication. This may include a dangerous rise in blood pressure, as well as headache, nausea, vomiting, rapid heartbeat, possible confusion, psychotic symptoms, seizures, stroke and coma. The foods that interact with MAOIs include aged cheeses, smoked, pickled, fermented and otherwise processed meats, fish and soy products; red wines, fava beans and ripe figs, and food containing monosodium glutamate (MSG). These foods all contain large amounts of the amino acid tyramine which, when it interacts with MAOIs, dramatically raises blood pressure. Medication Issues for Guardian Advocates An informed consumer, or the Guardian Advocate on his/ her behalf, is responsible for actively seeking information, reviewing alternative treatments and selectively authorizing appropriate treatments. After authorizing treatments, Guardian Advocate Training and Resource Manual 2006 Appendix D - 7

8 the consumer or Guardian Advocate still remains responsible for observing the effects of treatments and for making decisions about their continuation or change. In undertaking these decisions some medical information and context may be helpful and reassuring. Most people readily understand how important trusting one s physician is to establishing a positive and successful therapeutic relationship for recovery. However, no medical practitioner s judgment, as with any other profession, should be viewed as infallible. Often there may be reasonable disagreement between physicians as to the best treatment for a particular person s condition. In treatment settings, there are also occasions for unintended errors, such as nurses or other facility staff misunderstanding or imprecisely implementing the physician s medication or treatment orders. There is always a balance between exercising informed consent (active questioning) and the establishment of trust and a therapeutic alliance between the doctor, the person, and the Guardian Advocate. Trust, while essential, is based upon time and experience and is not blindly given between human beings. Rather, trust between people must be earned via information sharing and effective, ongoing person-to-person communications between all individuals involved. In most human encounters, including doctor-patient relationships, there is a certain tension about sharing too much information, being misunderstood, and openly expressing fears, feelings, anxieties and concerns. However, to the degree that trust can be established, such mutual respect and partnership for recovery is often the most effective road to recovery and health. Consequently, the following information is provided so that in representing the person, you may be a better informed advocate and be attentive to possible missteps or inattention that can occur. 1. Is There a Set of Clearly Defined Target Symptoms? A person must have a specific psychiatric diagnosis before the doctor begins the process of treatment planning and medication selection. The diagnostic process is based upon the doctor identifying certain common or characteristic target symptoms, and the course of the person s illness. Monitoring these same target symptoms provides the basis for evaluating the effectiveness of the treatments or medications. These target symptoms may be easily observable or be subjective (which means that we must infer or guess what the person is experiencing). A directly observable target symptom might be hyperactivity (restlessness and agitation). An example of a subjective symptom might be auditory hallucinations such as hearing voices. You should always ask the doctor: What symptoms are being monitored? What is the expected effect of the medications on these target symptoms? What effect has been observed upon these symptoms? What are the most common side effects of this medication? Accordingly, a key measure of a person s response to any medication should be How well is this medication reducing the symptoms? For example, evidence of a medication s effect may be observed in any of several dimensions of the symptoms such as severity, intensity, frequency, or duration. 2. Has a Medical Assessment Been Completed Prior to Initiating Medication Therapy? Upon admission to a hospital, all people who are to receive psychiatric medication therapy should be given a medical examination before psychotherapeutic medication is given. A physical exam, and in most cases a laboratory evaluation of key blood tests, should routinely be performed. These exams are important to ensure that the person s presenting problem is not the result of an undiagnosed non-psychiatric medical illness such as epilepsy or diabetes. Any laboratory tests ordered will depend on the person s age, medical history, current physical condition, and the medication being prescribed. For example, Lithium can be toxic to the thyroid gland and/or the kidneys. A person for whom this medication is being prescribed should have a Appendix D - 8 Guardian Advocate Training and Resource Manual 2006

9 baseline thyroid and kidney function study which is used as a bench mark for future determination of the person s response to the medication. 3. Has the Person Been Sufficiently Informed of Treatment Alternatives, Medication Side Effects and Outcomes? Informed consent on the part of the person or the person s Guardian Advocate is the cornerstone of treatment for mental illness. As the Guardian Advocate, the psychiatrist will be asking you to give informed consent for the person. Informed consent will be requested and accompanied by a presentation of information. Subsequently you will be asked to sign a form that authorizes treatment. Before you sign, the key treatment provisions you are agreeing to will be written onto the consent form. By signing the form, you are authorizing the treatments described on the form. Be careful to KEEP A COPY of the form that you sign. Information on Treatment Alternatives: At a minimum, the doctor or nurse is required to inform you about the purpose of the treatments recommended (e.g. treating target symptoms ), and about alternative treatment options that are available. They are also required to inform you about: The medications being recommended, The range of dosages anticipated for each medication (e.g mg), The frequency for each medication (i.e. take the medication twice a day, or three times a day), The side effects of the medications (side effects of a medication can range from mild discomfort, to painful, or harmful effect), and Prior to discharge, provision of a written list to the person listing all prescribed medications with corresponding dosage amounts and frequencies, and education on potential adverse drug interactions between these prescribed medications with other commonly used medications. (For example, some psychotherapeutic medications interact badly when taken along with common cold medicines or some foods). This comprehensive list of prescribed medications can subsequently be used to show to the person s doctor(s) or pharmacist to help avoid unwanted drug interactions. You should always feel free to ask additional questions if you don't understand information being presented, or are uncomfortable with an explanation given. After due consideration, you may either give informed consent or withhold informed consent. Psychotherapeutic medications generally come in three forms: Tablets or capsules taken orally, A concentrate of the medication presented in a liquid form, or Intramuscular injections of the medication (shots). A special type of long-lasting intramuscular injection is called a "depot form" of medication. The use of an intramuscular medication that is a depot form requires special consideration for informed consent purposes. A depot medication is injected into the muscle and then absorbed into the blood over a period of three to four weeks. In giving informed consent for this depot type of medication you must realize that you, as the Guardian Advocate are, in effect, giving an irreversible approval for a medication which the person will experience for a three or four week period. Special consideration in this case is needed because there is no way to stop the medication once it has been injected and the person will continue to be affected by that depot form medication until it is totally absorbed into the blood stream. A "depot form" medication should not be used until after it is determined that the person is not allergic to the medication. The major use for "depot medications" is for people who do not like to take medication by mouth, or who struggle to take a medication with regularity and subsequently experience unwanted relapses, or for treating persons who do not achieve a therapeutic medication blood level by oral administration of medication. These "depot form" injection medications should never be used for the convenience of staff or administration, or as a way of avoiding consent issues. Guardian Advocate Training and Resource Manual 2006 Appendix D - 9

10 4. Are the Therapeutic Effects of Treatment Being Regularly Monitored? During the early phase of medication therapy, the daily dose is usually rapidly increased in order to achieve a therapeutic level of medication in the person s blood. Due to the rapidity of this change, the person s condition and target symptoms should be evaluated several times each week. While all staff members involved with the treatment of the person should be observing and documenting this progress, it is primarily the responsibility of the physician and the nurse to take the leadership in this active monitoring. This active monitoring for medication effects upon the target symptoms should also include active monitoring for side effects which is discussed next in question #5. The monitoring for treatment target symptom effect, and for any side effects, should be clearly recorded in the person s progress chart by the physician, the nurse, and other mental health professionals. 5. Is the Person Being Regularly Monitored for Side Effects? It is extremely important that medication monitoring (described above) also include observation for side effects of the medication. These side effects must also be closely monitored as they might indicate that the current medication should be adjusted downward, discontinued, or that treatment for the side effects should be provided. Side effect monitoring should be conducted continuously. Each drug has a specific set of side effects and these known side effect reactions, or their absence, should be looked for on a regular basis. As always, the performance of side effect monitoring and any findings or the absence of findings should be documented in the person s chart in the progress notes written by the physician, the nurse, and other mental health professionals. 6. Is the Person Being Under-Medicated? Psychotherapeutic medications will not be effective unless administered in sufficient amounts (doses) for a sufficient length of time in order to achieve a therapeutic blood level. The goal of medication use is to provide the most relief with the least risk (side effect). A common method of prescribing psychotherapeutic medications is to start with a low daily dose, gradually increasing the daily dosage until the appropriate therapeutic effect is obtained or the maximum daily dose (or blood level) for the particular medication has been achieved. If the expected therapeutic effect is not achieved in this manner, then the physician will usually discontinue that medication and try another. Sometimes a physician may prescribe a low dosage of two or more similar medications trying to achieve a combined total effect, this is not necessarily under-medicating. Unless you discuss these issues with the physician you will not know what the physician s approach to medication management and monitoring may be. Under-medication usually involves prescribing very low daily doses of a medication in order to avoid medication side effects. Unfortunately, this approach can result in not delivering sufficient amounts of medication to achieve the necessary therapeutic blood levels of the medication even when clinically appropriate. No physician would intentionally under-medicate, but sometimes it does occur. Sometimes there is reasonable disagreement between physicians as to just what is under-medication. As with most medications, the impaired functioning of the person s liver or kidneys, sometimes due to diabetes, alcoholism, or other injury, can be a crucial variable in lowering the maximum amount of a medication the person may be able to tolerate. Two more commonly reported reasons when under medication does occur, and that you should be aware of are: A cautious physician may be reluctant to progressively prescribe higher dosages, because of the risk of possible adverse side effects, which might result in discomfort, or injury to the person. Some physicians whose experiences are more of a general practice nature may be uncomfortable or not fully aware of, the effects of normal or high dosage medications and, therefore are reluctant to prescribe sufficient amounts. Appendix D - 10 Guardian Advocate Training and Resource Manual 2006

11 7. Is the Person Being Over Medicated? Over medication is of special concern when using antipsychotic medication to treat disorders, because of the high correlation between high daily doses and the major side effects (which can be permanent) such as Parkinsonism (uncontrollable rigidity and muscular shakes), akathesia (uncontrollable restlessness of major muscles), and tardive dyskinesia (distorted movements of bodily or facial muscles, eyes, tongue, or lips). Consequently, close attention must be paid to the appearance of such side effects. However, in some cases, these side effects can also occur at normal dosage amounts that are well within the effective therapeutic range. Sometimes these side effects can be transient, and can be effectively adjusted by lowering the amount of medication and careful monitoring by the doctor. Five of the more commonly reported circumstances of over-medication you should be aware of are: A person's "target symptoms" of depression may be unresponsive to the prescribed antipsychotic medication. If the person, who is suffering from depression, is being incorrectly treated with an antipsychotic drug, then the person may continue to experience the debilitating symptoms of depression. In turn, this lack of therapeutic effect may lead the doctor to further increase the amount of medication. In the absence of a person exhibiting "target symptoms" of psychotic behavior, the increased dosages of the antipsychotic medication is not likely to help to lessen the person's depression. As the antipsychotic dose is increased the person will likely exhibit more and more side effects. If misused, antipsychotic medication therapy can worsen the person's mental illness. Involuntary motor restlessness (akathesia), for example, can be brought on by the antipsychotic medication and misdiagnosed as agitation. The doctor might then assume that the person is under medicated and increase the daily dose. At this point the person's agitation may worsen, thereby creating a vicious circle of increasing restlessness and increased medication. When more than one antipsychotic medication at a time is being prescribed, it is often difficult or impossible to determine which medication is having the favorable effect for the person. When two antipsychotic medications are being used, the overall dosage of those medications is additive. For example, if the person is receiving 10 mg of Haldol and 200 mg of Thorazine or Mellaril, the total effect on the person will be cumulative, or the approximate total sum, of the Haldol plus the Thorazine or Mellaril. If depot injection type medication therapy is being used (see #3), the person might receive injections more often than required. For example, if the original dosage injected is sufficient for a three-week medication period, and then an additional dose is then given at the end of the first week, the person will then be receiving approximately one third more medication than was originally prescribed. The use of a daily prescription of medication, plus an additional dosage such as a P.R.N. (give dose as needed) or a STAT (emergency, one time only dose), can result in a higher total daily dosage than is recommended. Further, the use of intramuscular injected P.R.N. or STAT dose of a medication can be even more likely to exceed the total recommended daily dose since injection medications may be up to four times more potent than an oral dosage. When reviewing a person s records, the following terminology is needed to read the physician s medication orders or nurse s medication administration chart. QD means daily, BID means twice a day, TID means three times a day, QID means four times a day, QOD means every other day, and HS means hour of sleep (at bedtime). 8. Is the Medication Therapy Being Changed Too Rapidly? When a person is in an acute stage of illness, a series of medications may be tried in rapid succession. Generally this occurs due to an understandable desire to obtain a prompt therapeutic effect upon the severe target symptoms, and sometimes it is necessitated due to an unwanted side effect of the medication being tried. In part, this occurs because it often can take a few days to a week to reach the necessary blood levels for a medication Guardian Advocate Training and Resource Manual 2006 Appendix D - 11

12 to demonstrate the desired effect. Such rapid changes, from one medication to another, are generally discouraged because none of the drugs were prescribed for a sufficient length of time or at a high enough daily dose to be effective. Hospital medication protocols or clinical guidelines on dosage ranges for various medications can offer guidance to doctors and concerned parties. 9. Are P.R.N. and STAT. Doses Being Used Excessively? When P.R.N. and STAT. medication doses are used for periods greater than a few weeks, this usually indicates one of the following: That the person's daily dose may be less then the therapeutically necessary amount, That the "target symptoms" will not respond to the prescribed drug, or That the medication is making the problem worse. For example, if the person appears to be improving with these additional medications, then an increase in the daily dosage may be indicated. If P.R.N. or STAT. doses are being regularly administered over a period of time, then the person's drug regimen should be reassessed. Remember, however, that in the early stages of treatment the appropriate use of P.R.N. or STAT. medications may be helpful in quickly resolving instances of severe, immediate symptoms without unnecessarily using higher routine dosages of medication or increasing the danger of unwanted side effects. 10. If the Person is Being Treated with Antipsychotic Medication Therapy, are Regular Examinations for Movement Disorders and Tardive Dyskinesia Being Carried Out? Persons receiving antipsychotic medication therapy for longer than a few months may be at risk at developing tardive dyskinesia. They should be examined for any of these potentially irreversible side effects at least semi-annually, or better quarterly. Early detection of the side effect and the subsequent discontinuation of the medication therapy may minimize the longterm consequences of tardive dyskinesia. The AIMS checklist is useful for diagnosis of tardive dyskinesia. The newer medications, known as atypical antipsychotics, do not seem to produce the tardive dyskinesia side effect. 11. Is Medication Therapy Being Prescribed for an Indefinite Period of Time? No medication therapy should be undertaken for an indefinite period of time without a planned review date. Planned drug reduction or withdrawal trials should be candidly discussed with persons routinely using antipsychotic medications as the best means of fully assessing the presence of certain hazardous side effects. For example, antipsychotic medication therapy can hide the onset of tardive dyskinesia. Consequently, the presence of tardive dyskinesia can best be fully examined and determined when the person has not taken any antipsychotic medication for several weeks. For some persons, however, the seriousness of their illness, or history of relapse, may preclude a total withdrawal due to the risks it may present. In all instances, such potentially permanent side effects must be closely monitored and the risks fully disclosed. In conclusion, psychotherapeutic medication therapy is the most effective treatment available for many types of mental disorders. However, it is a two-edged sword. The too ready use of these medications can also cause significant physical and psychological harm. It is the responsibility of the treating physician to: Fully inform you of the alternatives and risks in seeking your consent to treat and Prescribe these medications in accordance with current standards of best practice. As always, however, it is the duty of the Guardian Advocate to: Ask questions of the physician and Pay close attention to the answers given, both during the informed consent process and during the continuing treatment phase of the person's stay in the facility. 12. Has the Person Received Information on Potential Adverse Drug Interactions of his/her Psychotherapeutic Medication with Other Commonly Used Medications? In some instances the necessary psychotherapeutic medication should not be taken in combination with other commonly used medications or foods Appendix D - 12 Guardian Advocate Training and Resource Manual 2006

13 (such as some cold medications, anti-inflammatory medications, alcohol, or the use of illicit drugs). This is important because taking some other medications may cause changes, or increase, or decrease, the effect of the psychotherapeutic medication. Both your doctor and pharmacist are good sources of information for possible unwanted drug interactions. Prescription medications interact with other prescription medications. Prescription medications also interact with over-the-counter medications. While many of these interactions are well-known, the person must also be aware and ask about such potential interactions before taking medications. Interactions are not side effects, but rather one drug interacting with a newly prescribed drug in some often well-known manner. While such drug-to-drug interactions can be dangerous, and sometimes life threatening, the greatest danger usually lies in the reduced effect or increased effect of the psychotherapeutic drug being administered. These sometimes subtle changes can be enough to abort the person s immediate recovery, and have the possibility of going unnoticed by the doctor unless discussed. This is very important information for persons that are leaving the facility and returning to their homes. After leaving the facility, persons continuing on medications must be aware of possible adverse interactions with their particular psychotherapeutic medications. Prior to discharge, the facility should provide the person with a written listing of all prescribed medications with corresponding dosage amounts and frequencies. This comprehensive list of prescribed medications can subsequently be used to show to the person s doctor(s) or pharmacist to help avoid unwanted drug interaction. Guardian Advocate Training and Resource Manual 2006 Appendix D - 13