Psychotropic Medications: How to Manage in Remote Programming

Back in 1980 I became a somewhat disillusioned psychology major at the University of Colorado when upon taking a cooking job in the local psychiatric hospital, I discovered that mental healthcare was all about psychotropic medications.

Ten years later at Outward Bound, instructors were having anxiety attacks when reviewing their students’ medical forms and seeing the prevalence of psychotropic medication use.

Since then I have worked in and with a variety of programs which operate in remote or international locales, all of which have wrestled with how to manage potential issues for students/participants who were taking a variety of psychotropic medications.

The data collected at Outward Bound at that time and all of my experience since indicates that most students taking psychotropic meds do fine and do not appear in incident reports any more frequently than students not taking psychotropic medications. However, that isn’t to say that psychotropic medications are not significant contributing factors in a variety of ways. I have had students attempt to commit suicide by overdosing on their meds. I’ve seen students have breakthrough disorders when the stresses of the programs exceeded the stresses of their home environments. Students have shared out their medications with other students for recreational purposes (usually combined with alcohol), discontinued their meds without telling anyone, and been surprisingly under educated about side effects.  I have also seen a number of food, drug and environmental interactions (frostbite, heatstroke, severe sunburn, etc) where the students’ medications were contributing factors.

While most students in most programs manage their own medications, it behooves program managers and field staff to have some level of understanding in order to help prevent, or more effectively respond to, incidents where they play a contributing role. Depending up the Who/What/Where/When/How/How Long of your program you might want to know the answers to the following questions about a particular medication:

• Does the drug have overdose/suicide potential?
• Does the drug have any recreational/abuse potential?
• Is there a stabilizing period to ascertain if the drug is going to be effective, and has that period passed?
• What would happen if a dose or two were missed, or if it was discontinued?
• Is it legal in the countries we are traveling in?
• Is there a redundant supply if some were lost/destroyed?
• Are there any side effects that have implications for our environment, i.e., photosensitivity or sweating/shivering inhibition, etc.
• Are there any food or drug interactions that we need to be aware of?

Now, many programs take the view that none of this is their responsibility. After all, you don’t have that sort of expertise. However, if a safety incident occurs where a psychotropic medication was a significant contributing factor, it will be small consolation to your program that you have a partial justification that it isn’t your fault. And, from a liability perspective, the potential lawsuit would not focus on the specifics of the drug or the student’s behavior with regard to the medication. It would be about your responsibility for caring for anyone who was having any compromised health or safety issue. Your best protection is to take some fundamental steps for prevention and response. In the real world of limited program budgets, time and personnel, it is unlikely that you are going to develop real in house expertise. However, some reasonable steps would be:

• As part of your screening process, ask participants to indicate what psychotropic medications they are taking.
• With signed permission from your participant, ask the prescriber the appropriate questions. Inform the prescriber of the nature of your program in a paragraph or so and ask them to sign a brief statement indicating that in their professional opinion the participant’s use of the particular psychotropic medication does in no way present a barrier to participation in the program.
• Have policies in place that define the criteria for participation in your program in regard to psychotropic meds, i.e., no one is permitted to discontinue a medication just prior to participating in your program; no one is permitted to participate in the program without having stabilized on their current medication, etc. You don’t want to invite a lawsuit by barring someone solely based on their medication, but it may make sense to defer participation.
• Determine if there are appropriate and reasonable ways to manage side effects, photosensitivity, thermoregulation, etc. If it is determined that this is not the case, try to persuade the participant that this is not a good idea for them. If they insist, you can require them to sign a waiver indicating that you have communicated your concerns.
• If operating in another country, check in with the US Embassy or a country national pharmacist to find out about the legality of the medication. If you subscribe to a travel assistance provider, they may be able to help with this as well.
• Have an advisory physician or psychiatrist who is willing to be available to answer questions if the need arises either during the screening process or during the program.
• As a regular practice, have staff check in with students regarding their medications and related mental health issues. This should be done in a low key and confidential manner.
• Balance confidentiality concerns with ensuring that staff who need to know, do know.
• Educate your staff on some fundamentals about psychotropic medications.  A partial curriculum might include:
  • Mental health diagnoses are based on the Diagnostic Statistical Manual VI Revised. It is based on listings of particular behaviors or reported experiences. When an individual manifests a certain number of diagnostic traits, they are labeled as such.
  • There is significant variability across individual responses to medications and those responses may evolve over time.
  • Psychiatrists, MDs, DOs, PAs, Nurse Practitioners, etc. can all prescribe medications. Some do a better job than others in educating their patients. Many students may not be familiar with the potential environmental, food and other medication interactions with their medication.
  • There is significant latitude in what is prescribed for what condition. Antidepressants are often the first choice for anxiety disorders. Stimulants and antipsychotics are sometimes prescribed for depression. You should know both the nature of the medication and the condition that it was prescribed for.
  • Antidepressants and mood stabilizers can take weeks for therapeutic effect and months to become stabilized. Stimulants and benzodiazapines become stable relatively quickly.  A policy that insists on stabilization before participation is prudent.
  • Most antidepressants, mood disorder medications and antipsychotics have little significant recreational/abuse value. Benzodiazapines and stimulants (particularly snorted Adderall) have significant abuse potential.
  • While anything in sufficient doses could kill you, most psychotropic meds are not particularly lethal, the exception being MAO Inhibitors, an older generation category of antidepressants that are still prescribed for patients who do not respond to newer antidepressants. Benzodiazapines, when combined with alcohol, could also be fatal. Barbituates, rarely prescribed anymore, can be very lethal as well.

So…the majority of your students and staff on psychotropic medications will likely be fine on your program, but it makes sense to be sure that you know what students/participants are taking, to ask the right questions of the prescriber, to implement appropriate participation policies, to be aware of the most common environmental interactions (if you operate in a hot, cold or tropical sun environment), to be aware of potential overdose and abuse potential, to educate your field staff, to have an advisor with the appropriate expertise, and you might consider keeping a Physician’s Desk Reference (PDR) or website equivalent handy.