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Posted:
Aug 14, 2006
13:50
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MEDICATIONS IN A RESIDENTIAL SETTING
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By: Megan Slater, RN, Nursing Director
New Haven
Provo, Utah
801-768-2495
www.newhavenrtc.com
When a student is admitted to New Haven, which offers a short-term residential setting, the medical department faces a few different scenarios:
- The parents have gone through an ordeal with their daughter's behavior and tried many medications. They have finally found the medications they feel are helping their daughter and are resistant to the idea of changing them.
- The parents have gone through a tough time with their daughter but have not yet found a medication they feel is beneficial.
- The parents and/ or their daughter are very resistant to taking any kind of medication. Sometimes it stems from having had a bad experience in the past; at other times they are against medications in general.
- The daughter feels her mood problems are severe and is either reluctant to go off of medications, or she is medication seeking-she asks excessively for the doctor to put her on new medications.
- The family or their daughter feels that she has been over-medicated.
Getting a Baseline
Our policy is to deal with all of these scenarios in the same way. Upon admission, we tell the parents that we will monitor their daughter's mood and behavior carefully for the first three to four weeks before making any decisions about their medications. Some parents have a hard time waiting this long-they have often witnessed extreme behavior from their daughter in the past and are anxious to get her stabilized.
During the first month it is critical for the Treatment Team (members of every discipline that meet weekly to discuss the treatment of the girls) to observe the students and get a baseline of their moods. We take into account their past history, their present behavior, the issues they are dealing with in therapy and the overall moods they exemplify.
The psychiatrist will have initially met with the parents and the student to get a history of what medications have been tried, if any, and what has/ has not been helpful. The teachers report on the student's behavior in a school setting. Staff monitor how she responds to "down time" and activities in the community. The Primary Therapist, Family Therapist and Recreation Therapist focus on how her issues are affecting her mood and behavior. The Nurse works with the student on her medication management.
After the initial diagnoses have been made, the Psychiatrist talks with the student about how she feels her mood is. If it is clear that her depression or anxiety is out of her control, the doctor will suggest to the family that we try a different medication. On the other hand, if the student is displaying consistency in mood and behavior, we may try to see if she really needs the medications that she is on.
Residential vs. Short-term treatment
Parents with a daughter who has completed the program are often perplexed at why their daughter, who needed several psychotropic medications at home, is now stable on only one or two medications. They saw the "best psychiatrist" in their area, and he couldn't have been wrong, could he? Often times, he wasn't.
Most likely, their home psychiatrist saw their daughter in a moment of crisis. She likely had exhibited dangerous behavior, anger, sadness, poor decision making, etc. The outpatient psychiatrist and the psychiatrist at the Psych Hospital had to deal with the problem at hand, which was to get the student under immediate control. They make the majority of their diagnoses based on information and behavior at present.
The long-term nature of a Residential Treatment Center offers a unique opportunity for the family to get their daughter out of crisis and stabilized in a controlled, structured environment. The length of stay and Treatment Team feedback help us filter out what mood problems were due to the issues she experienced at home, as opposed to what is truly a chemical problem.
A Best Case Scenario
I will use a former student as an example (name has been changed for confidentiality). Jamie came to New Haven on Trileptal, Abilify and Lamictal. Her family was supportive of her previous diagnosis of Bipolar disorder. Jamie's issues were Substance Abuse, Trauma, Sexual Reactivity, Family Relations and Mood Instability. The Treatment Team immediately posed a couple of questions: How much of her mood instability is due to her drug use and trauma? What role does the family tension play in regards to her mood and substance abuse? What can we immediately do to help her feel safe?
As treatment progressed for Jamie, her mood remained stable. Despite working through hard issues, she was able to stay level. The Psychiatrist suggested to the parents that we try weaning her off of the Trileptal to see how she did. Hesitantly, her parents agreed. A few months later, she was weaned off of the Abilify. The Treatment Team was of the opinion that Jamie was not Bipolar. The parents, happy with the results so far, asked about the possibility of taking Jamie off of the Lamictal as well.
Before that change could be made, Jamie began to regress. Her mood became unstable. It was decided to keep her on the medication during this hard time for her. She was doing heavy trauma work in therapy and her mood was fluctuating. Her parents began to question the wisdom in taking her off of the earlier medications. The Treatment Team asked them to be patient and see what happened as Jamie faced her hardest issues.
Ultimately her mood stabilized and she completed the program. She was advised to stay on the Lamictal for 6 months after going home, at which time if she was stable, she could discuss with her home Psychiatrist the benefits of discontinuing the Lamictal.
Willingness to Try
The above example is a best-case scenario. It doesn't always work out that way. Sometimes students are admitted who have never been on any medications before. Their mood is out of their control. They have to be willing to try different medications until they find one that works for them. It can be tedious and requires patience from the parents, student and the staff.
Because New Haven is family-focused, a lot of work is done with the parents with regard to medication education. They meet with the psychiatrist at Family Weekends and are welcome to call the nurse as needed. If they are against the idea of their daughter taking medication, they are encouraged to trust the experience of the New Haven staff. We educate them on how the chemicals work in the brain and the rationale behind using medications.
Again, our most important task is to create a safe environment for them so that they are willing to trust us and work with us. Both the parents and the student have to be on board with their treatment program. In rare instances, we are not able to find the right combination of medication for a student.
Research into New Haven's medication history from 2002 to present indicates that students who have no medication changes while in treatment at New Haven are less likely to complete the program than those who do. This includes both students who came in on medications as well as those who were on none to begin with.
I am not suggesting that medications were the sole factor in their progress. Rather it is the family's willingness to explore their options, their ability to "surrender" to the program their level of trust in New Haven that is a huge indicator of their likelihood to succeed. Medications are part of that. Are the parents or the student willing to address the benefits/cost of the medications the student is taking (or not taking)? Do they trust what the Treatment Team is seeing and, consequently, what information is being relayed to the Psychiatrist? Are they willing to take a risk with the medications?
A Lengthened Approach
The Residential setting and team approach allow us at New Haven the effective opportunity of observing the students over a long period of time (6-9 months average), and of seeing how the student behaves in all aspects of her life. When combined with our Home Haven program (which tracks and supports the families for 3 months after discharge) we have a good chance of helping the student find the medications that are right for them.
About the Author:
Megan Slater, RN, is the Nursing Director at New Haven. She started at New Haven in 1996 and was a staff supervisor. After completing her nursing degree at Utah Valley State College, she became a member of the nursing staff. Megan likes community nursing and enjoys working at New Haven because of the on-on-one time that she is able to have with the girls. Megan and her husband have four children.
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