Behavioral Health Medical Services California Criminal Justice Reform:

Behavioral Health Medical Services California Criminal Justice Reform:

Behavioral Health Medical Services California Criminal Justice Reform: Recidivism Reduction Training Psychotropic Medication in Treatment Courts Teresa Frausto, M.D. Chief Medical Officer April 13, 2016 Disclaimer Page 2 No conflict of interest. Behavioral Health

Goals of Presentation Page 3 History of the mentally ill in corrections. Review common diagnosis and medication treatments. Discuss treatment challenges. Behavioral Health Origins of the Community Mental Health System Page 4 Deinstitutionalization of the severely mentally ill led to the trans institutionalization to the jails and prisons. Funding from the cost savings achieved through the closures of the state hospitals to the community mental health system did not occur.

Unlike services to persons with developmental disabilities, the mental health system was never conceived as an entitlement. Mental health services were to be provided to the extent resources are available. Behavioral Health Origins of the Community Mental Health System Page 5 Although deinstitutionalization was well intentioned, the failure to provide treatment needs to the severely mentally ill has turned this policy into one of the greatest social disasters of the 20th century. Behavioral Health Assembly Bill 109 Page 6 Release of lower level offenders from the prisons back into the community. Establishment of the Day Reporting Centers. Change in the population of the jails with more acute and chronic medical and mental health problems. Behavioral Health Psychotropic Medications Page 7 Most Commonly Used

Antipsychotics; Antidepressants; Antianxiety (Anxiolytic); Mood Stabilizers; Psychostimulants; and Others. Behavioral Health Antipsychotics - Indications Page 8 Indications

Psychotic symptoms Schizophrenia, Schizoaffective Psychotic Symptoms Other applications Delirium/dementia Substance induced psychosis/agitation Severe aggression and violence behaviors Severe Personality disorder Behavioral Health

Antipsychotics - Treatment of Symptoms Page 9 Psychotic Symptoms Positive symptoms Hallucinations, delusion, disorganization, Agitation Negative symptoms Alogia (speech), Avolition (drive), Anhedonia (pleasure), Apathy (flat affect) Behavioral Health Antipsychotic - Medications

Page 10 Atypical Antipsychotics Clozapine (Clozaril) Risperidone (Risperdal) >>> (Risperdal Consta) Olanzapine (Zyprexa, Zydis)>> (Zyprexa Relprev)* Quetiapine (Seroquel, Seroquel XR) Ziprasidone (Geodon) Aripiprazole (Abilify) Paliperidone (Invega) >>> (Invega Sustenna)* Iloperidone (Fanapt)*

Asenapine (Saphris)* Lurasidone (Latuda)* * Newer AP & Long Acting injectable AP Behavioral Health Antipsychotic - Adverse Reactions Page 11 Sedation, weight gain and cognitive dulling Extrapyramidal symptoms (EPS) Diabetes, Hypertension, increases in Cholesterol Cardiac changes for example arrhythmias

Behavioral Health Antidepressant - Indications Page 12 Indicators Depressive Disorders Major Depression Dysthymia, Depression not otherwise specified Anxiety Disorders Panic disorders, Social Phobia Post-traumatic Stress Disorder (PTSD)

Other applications Eating disorders, Obsessive Compulsive Disorder Premenstrual Dysphoric Disorder Migraine, pain disorders, impulse control disorders Behavioral Health Antidepressant - Treatment of Symptoms Page 13 Depressive Symptoms Pervasive depressed mood, Excessive guilt feelings, hopeless & helplessness Psychomotor agitation or retardation

Severe sleep disturbances Anhedonia, poor concentration Preoccupation with physical health Delusional / Suicide thoughts Behavioral Health Antidepressant - Medications Page 14 Traditional Antidepressants* Monoamineoxidase Inhibitors(MAOI) Phenelzine (Nardil) Tranylcypromine (Parnate) Tricyclic Antidepressants (TCAs)

Amitryptyline (Elavil) Imipramine (Tofranil) Doxepin (Sinequan) Clomipramine (Anafranil)** * Able to measure therapeutic drug level ** Mainly for OCD Behavioral Health Antidepressant Medications (continued) Page 15 Traditional Antidepressants (continued)

Nortryptyline (Pamelor) Desipramine (Norpramin) Protryptyline (Vivactil) Trimipramine (Surmontil) Amoxapine (Arsendin) Behavioral Health Antidepressant Medications (continued) Page 16 Newer Antidepressants Serotinin reuptake inhibitors (SSRIs)

Fluoxetine (Prozac) Paroxetine (Paxil, Paxil-CR) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Fluvoxamine (Luvox / Luvox CR)* Vortioxetine (Brintellix) * Primarily for OCD Behavioral Health

Antidepressant Medications (continued) Page 17 Newer Antidepressants (continued) Serotonin-Norepinephrine reuptake inhibitors Venlafaxine (Effexor, Effexor XR) Duloxetine (Cymbalta) Desvenlafaxine (Pristiq) Levomilnacipran (Fetzima) Behavioral Health Antidepressant Medications (continued)

Page 18 Other Atypical Antidepressants Mirtazapine (Remeron) Bupropion (Welbutrin, Welbutrin SR, Wellbutrin XL) Trazodone (Desyrel) Vilazodone (Viibryd) Vortioxetine (Brintellix) Behavioral Health Antidepressant - Adverse Reactions

Page 19 Orthostatic Hypotension Dizziness, Tachycardia Sedations, Weight gain Hypertensive Crisis Dry mouth, blurred vision, constipation Conduction disturbances Seizures Tremors, Ataxia, Delirium (toxic level) Erectile & ejaculatory dysfunctions Behavioral Health Anti-Anxiety - Indications Page 20 Anxiety Disorders Panic Disorder, Phobias including Social Anxiety Disorder Generalized Anxiety Disorders, Acute Anxiety Anxiety due to specific stressful life event(s) Other applications* Substance withdrawal As Hypnotic / Sedative * Primarily for Benzodiazepines Behavioral Health Anti-Anxiety - Treatment of Symptoms Page 21 Anxiety Symptoms Excessive worry & anxiety Restlessness or feeling on edge Easily Fatigability Difficulty concentrating Irritability, Muscle tension Sleep disturbances *Symptoms cause significant distress in daily social functioning

Neuropsychiatric basis of treatment GABA receptors, Serotonin, Chloride ions Behavioral Health Anti-Anxiety - Medications Page 22 SSRIs First line treatment for Anxiety disorders

Fluoxetine (Prozac) Paroxetine (Paxil, Paxil-CR) Sertraline (Zoloft) Citalopram (Celexa) Escitalopram (Lexapro) Effexor, Effexor XR FDA approved for Generalized Anxiety Disorder Duloxetine (Cymbalta) Behavioral Health Anti-Anxiety Medications (continued) Page 23 Benzodiazepines

Alprazolam (Xanax / Nirivum) Clonazepam (Klonopin) Diazepam (Valium) Lorazepam (Ativum) Non-Benzodiazepine Buspirone (BuSpar) Hydroxyzine (Vistaril, Atarax) Behavioral Health Anti-Anxiety - Adverse Reactions Page 24 SSRIs No immediate relieve of anxiety symptoms

Safer long term side effect profile Anxiolytic Benzodiazepines Most common Sedation, Ataxia, Dizziness, Cognitive impairment, Anterograde amnesiae Respiratory depression Abuse, Dependence Tolerance, Cross-tolerance, Withdrawal Behavioral Health Mood Stabilizers - Indications Page 25

Indications Principle applications Treatment of Mania and Bipolar Disorders Mood Disorders including Schizoaffective Disorder Cyclothymia, Unipolar Depressions Other applications Impulse Control Disorders Severe Personality Disorder Neuropsychiatric basis of treatment Second messenger system (Inositol, Arachidonic Acid, PhospholipaseA2) Behavioral Health Mood Stabilizers - Medications Page 26 Mood stabilizers Standard mood stabilizers Lithium (Eskalith, Eskalith CR, Lithonate) Valproate/ Divalproex (Depakene, Depakote) Carbamazepine (Tegretol) Newer mood stabilizers Lamotrigine (Lamictal)

Topiramate (Topamax) Oxcarbazepine (Trileptal) Behavioral Health Mood Stabilizers - Adverse Reactions Page 27 Lithium Most common GI side effects ~ nausea and vomiting, Fine tremor, Fuzzy feeling Less common

RenalPolyuria, polydipsia, Diabetes Insipidus ThyroidHypothyroidism DermatologicalRash & Acne Neurologicalmuscle weakness, slurred speech (transient) CardiacEKG changes, Edema HematologicalBenign Leukocytosis Behavioral Health Adverse Drug Reactions (continued) Page 28 Lithium toxicity Symptoms

Nausea, Vomiting, Diarrhea, Coarse tremor, Ataxia, Headache, Slurred speech, Confusion & Cardiac arrhythmia may occur Causes Reduced fluid intake, Increased fluid & electrolytes loss (Excessive sweating, Diarrhea), Overdose Drug interaction (Increased level by Diuretics, Non Steroidal Anti Inflammatory) Behavioral Health Neurotransmitter Related Reactions Page 29 Neurotransmitter related reactions*

Anti-cholinergic reactions Dry mouth, Constipation, Urinary retention, Blurred vision Anti-alpha adrenagic reactions Orthostatic hypotension, Sedation, Techycardia Anti-histamine reactions Sedation, fatigue, Weight gain*, Hyperglycemia* Anti-dopamine reactions Parkinson like symptoms (masked faces, tremors, dystonia, shuffling gait) Hyper Prolactinemia (Galactorrhea)

Akathisia Miscellaneous Hyper/hypothermia, photosensitivity, lower seizure threshold, rash, EKG changes (QT interval), Agranulocytosis *Anti-5HT1C ~ new warning for all Antipsychotic medications Behavioral Health Treatment Challenges Page 30 How to get a mentally ill patient to: Take their medications? Stay on their medications?

Behavioral Health Treatment Challenges (continued) Page 31 What about forced medications? Behavioral Health Treatment Challenges (continued) Page 32 When do you know the patient is stabilized on medications? Behavioral Health Community Reentry Page 33 Development of a Release Team to ensure a warm hand off of patients to community providers upon release. Increase in patients receiving follow up mental health and substance use services in the community after release. Behavioral Health Thank you! Page 34 Teresa Frausto, M.D. Chief Medical Officer County of San Bernardino Department of Behavioral Health

Behavioral Health

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