Jerry Floersch (Principal Investigator) Lisa Townsend, Victoria Winbush, Derrick Kranke, Michelle Munson,

1. Subjective Medication Adolescent Research Team Jerry Floersch (Principal Investigator) Lisa Townsend, Victoria Winbush, Derrick Kranke, Michelle Munson, Janis H. Jenkins, Jeffrey Longhofer, and Robert Findling Funded by the National Institute of Mental Health, #KMH068584A1

2. Disclosures: • Dr. Findling receives or has received research support, acted as a consultant and/or served on a speaker's bureau for Abbott, AstraZeneca, Bristol-Myers Squibb, Celltech-Medeva, Cypress Biosciences, Forest, GlaxoSmithKline, Johnson & Johnson, Lilly, New River, Novartis, Otsuka, Pfizer, Sanofi-Aventis, Shire, Solvay, Supernus Pharmaceuticals, and Wyeth. • None of the other authors have any relationships to disclose.

3. British Museum http://www.cradletograve.org/

4. Cooper W.O., Arbogast P.G., Ding H., Hickson G.B., Fuchs D.C., & Ray WA. Trends in prescribing of antipsychotic medications for US children. Ambulatory Pediatrics, 6(2), 79–83. • (2004) Wong I.C., Murray M.L., Camilleri-Novak D., & Stephens P. (2004). Increased prescribing trends of paediatric psychotropic medications. Archives of Disease in Childhood, 89(12),1131-32. • (2004) Lyons J.S., MacIntyre J.C., Lee M.E., Carpinello S., Zuber M.P., & Fazio M.L. Psychotropic medications prescribing patterns for children and adolescents in New York’s public mental health system. Community Mental Health Journal, 40(2), 101-118. • (2003) Zito, J.M., Safer, D.J., dosReis, S., Gardner, J.F., Magder, L., Soeken, K., et al. Psychotropic practice patterns for youth. Archivesof Pediatrics & Adolescent Medicine, 157 (1): 17-25. • (2002) Olfson, M., Marcus, S. C., Weissman, M. M., & Jensen, P. S. National trends in the use of psychotropic medications by children. Journal of the American Academy of Child and AdolescentPsychiatry, 41(5), 514-521.

5. Increase raises questions: • Clinical efficacy and effectiveness • Safety • Meaning

6. Meaning Making and Psychiatric Medications Chubinsky, P., & Rappaport, N. (2006). Medication and the fragile alliance: The complex meanings of psychotropic medication to children, adolescents, and families. Journal of Infant, Child, and Adolescent Psychotherapy,5(1), 111–123. Rappaport, N., & Chubinsky, P. (2000). The Meaning of psychotropic medications for children, adolescents, and their families. Journal of the American Academy of Child and Adolescent Psychiatry, 39(9), 1198-2000. Floersch, J. (2003). The subjective experience of youth psychotropic treatment. Social Work in Mental Health, 1(4), 51-69. Longhofer, J., Floersch, J., & Jenkins, J. (2003). The social grid of community medication management. American Journal of Orthopsychiatry, 73 (1), 24-34. Medical Anthropology………

7. General Aim • From the point of view of adolescents: • Why do I need medication treatment? • 2) What do medications do for me?

8. IRB approved, full review, Consent|Assent • Convenience, outpatient sample, from university hospital, and community mental health agencies • Subject inclusion criteria • ages 12-17 • Currently in treatment with a physician or psychiatrist • Currently prescribed a medication, and taken at least once in last 30 days

9. Teen Subjective Experience Medication Interview (TeenSEMI) • The TeenSEMI, approximately 150 questions, included three treatment and medication experience categories (Jenkins et al., 2005; 1997): • treatment, illness, and medication history • perceptions of medication • managing, monitoring, reporting of medication experience

11. *Percentage > 100% due to comorbidity

13. The treatment codes were sorted and 7 life domain dimensions emerged: • DIAGNOSIS • SELF • BEHAVIOR • BODY • COGNITIVE • EMOTION • INTERSUBJECTIVE

14. Why do I need medication treatment?

15. BODY • EMOTION • BEHAVIOR • COGNITIVE • EXPECTATION • INTERSUBJECTIVE • SIDE EFFECTS • SELF • DIAGNOSIS • The medication codes were sorted and 9 life domain dimensions emerged:

16. What do medications do for me?

17. What do medications do for me? (continued)

18. A second data analytic step was conducted to strengthen the significance of these findings. • Are the life domain dimensions a pattern across all respondents?

19. Quotation Frequency of Three Illness Life Dimensions

23. Illness and Medication Themes Compared (N= 20 respondents)

26. Why do I need medication treatment? • “ I think the reason why I’m going is because I have bipolar. I felt like I was doing fine, but I guess there were kind of different things going on.” (Diagnosis) • “I think it’s mostly because I had a really, really bad attitude and if I didn’t like what they [parents] said, I didn’t want to hear it, and if I didn’t like it and they kept telling me, I’d start screaming, so they knew something was wrong with me.” (Emotion) • “Because when I have a bad episode, I tend to black out, I don’t remember things…like these glasses. I took them when I was mad and I twisted them all up and …I don’t remember doing it at all. My mom just told me.” (double coded, Body and Behavior) • Like I would have outbursts every single day.” (Emotion)

27. Why Do I Need Medication Treatment? • [what do you think caused you to have these concerns?] “I’m not sure if this is really it, but the move [referring to moving out of grandma’s house after her death], because that just made my emotions go absolutely crazy. I mean I’ve lived in that house my whole life up to the 4th grade…That was my grandma’s house before she died, I mean, and I met my best friend at that house, and it just kind of felt like, oh my god. Look I’m just totally leaving, and it just made me really upset and made my emotions go crazy.” (Emotion) • “Well that’s when [six months after seeing a psychiatrist the first time] I first started to hear, they started saying bipolar, but also, I just remember two months into that, they had me ODD [oppositional defiant disorder], separation anxiety, and mania.” (Diagnosis)

28. Why do I need medication treatment? • “He [psychiatrist] kind of told my mom, before he told me, and then my mom sat down and explained it to me and we went and got some books from the library and we pretty much just read up on them and seen what they really were.” (Intersubjective) • “My best friend’s twin brother…we became really good friends…we [her friend] would always make jokes about him and laugh at him because he was bipolar…and he kind of explained to me what it was and how you have to just deal with it.” (Intersubjective) • “At first I was like, “no. I can’t be bipolar.” That’s just not me. I don’t want to be it and then when I started actually seeing what was really going on, I’m just like, oh my god, I can’t believe I just said that I wasn’t this, and now I am.” (Self)

29. What do medications do for me? • “I started taking medicine and I would see a total different person when I took the medicine. I mean I wasn’t so angry and I was able to have a good time and laugh and just have fun.” (triple coded, Emotion, Self) • [what went through your mind when medication was first suggested?] “I felt like they thought I was crazy.” (Self) • [do you recall what that first medication was called?] “Oh I can’t remember it. I know it’s always on TV with the little happy dot thing.” [how did that feel to you when you saw something on TV that you were taking?] “I just made fun of it a lot, like me and my mom. Like if I didn’t feel like taking it, my mom was like, “go take your happy dot pill.” (Intersubjective)

30. What do Medications do for me? Of the things you listed that medications do for your concerns , which is the most important to you? The aggression. (emotion) The aggression, of all things you want meds to take aggression away? Yeah. And does it? Yeah. How do you know that? Because. I mean with the medicine, when I was off of the medicine, I would kind of, like I’d always get in trouble for aggression. I got in a fight at school. I got suspended. I got put in the court system. I beat another girl up outside of school. I got put in the court system again. I mean I got in like ten fights in one year, and this year I haven’t got in one fight. Well I had one fight, and that was because the boy wouldn’t shut up. I asked him for like ten weeks straight to just not talk to me. (behavior)

31. What do medications do for me? • [if a medication could do anything you wanted for the concerns you have mentioned, what would you wish it could do for you?] “Nothing for me, mostly for my family. I feel that way so they won’t have to go through all the pain that they had to go through” (Intersubjective) • [what do you think the seroquel (antipsychotic) actually does for you?] “It’s my sleeping pill…I take it and I kind of get all goofy for like an hour, and then I’ll be really, really hungry and I’ll eat all these calories, then I’ll go to bed.” [so you couldn’t sleep before seroquel?] “I could, just not as well. Like if I heard my dog walking pass my bedroom, I’d wake up and didn’t know what to do, and I’d lie there for like two hours trying to go back to sleep, because I can’t fall asleep without my TV on. So I’d turn on my TV and just lie there, watch TV and not be able to go back to sleep.” [so seroquel helps you sleep all through the night?] “yeah.” (Behavior)

33. What do Medications do for me? ID 9, Male, age 17, (Bipolar, two antipsychotics and one mood stabilizer) Like I know sometimes if I don’t take my meds, they don’t help me. I mean I can’t fall asleep if I’m in bed sometimes. So they help me that way. ID 11, Male, age 15, (Major Depressive Disorder, 1 antipsychotic, 1 antidpressant, 1 mood stabilizer, and 1 psychostimulant) With my Topamax and Seroquel, I gain the ability to sleep at night and a life without headaches for the most part ID 15, Female, age 17, (Major Depressive Disorder, Eating Disorder, 1 antipsychotic, 1 antidepressant, and 1 mood stabilizer) It just makes me sleepy. It makes me go to sleep. I get restless and I can’t go to sleep and I’ll stay up all night, so I take Trazidone. I can take 100 to 200, depending on how much I need to go to sleep that night.

34. What do Medications do for me? ID 16, Female, age 15, (Substance-Abuse Mood Disorder, ADHD, ODD, 1 antipsychotic and 1 psychostimulant) It keeps me calm and happy, and at night I take Seroquel and I used to have nightmares really bad and I couldn’t sleep at all at nights, but now I can sleep. ID 17, Female, age 12, (Bipolar, ADHD, 1 antidepressant and 1 psychostimulant) I think it helps me to calm down at night to sleep, ‘cause that’s really what it does. ID 18, Female, age 14, (Eating Disorder, Enuresis, 1 antidepressant) When I’ve got to go to school, it makes me go to sleep at night.

35. What do Medications do for me? ID 22, Male, age 12, ADHD, Enuresis, 1 antipsychotic and 1 psychostimulant) It brings back my appetite and helps me go to sleep. How do you know that? ‘Cause I get real hungry in like one minute, then I fall asleep in two minutes.

36. Clinical Practice: