PSYCHOTROPIC MEDICATION CONSENT FORM

Psychotropic Medication Consent Form-Kids

Note: The following information is generalized by drug class and not to each drug within that class.

SNRI’s (SEROTONIN NOR-EPINEPHRINE REUPTAKE INHIBITORS): (EFFEXOR, CYMBALTA)

Indications: depression, social anxiety disorder, generalized anxiety disorder, panic disorder, neuropathic pain, fibromyalgia, musculoskeletal pain.

Anticipated Benefit: relief of depression, anxiety, and chronic pain symptoms

Potential side effects Include, but are not limited to: nausea, headache, insomnia or sedation, sexual side effects, irritability, increased blood pressure, suicidal thinking, mania (excessively high mood), low sodium level, rash, withdrawal symptoms with abrupt discontinuation, NMS (neuroleptic malignant syndrome: rigidity, fever, unstable vital signs), serotonin syndrome (increased temperature, increased heart rate, shivering, severe twitching), fetal abnormalities if taken in pregnancy.

SSRI’s (SELECTIVE SEROTONIN REUPTAKE INHIBITORS): (CELEXA, LEXAPRO, ZOLOFT, LUVOX, PROZAC, PAXIL)

Indications: depression, panic disorder, anxiety, obsessive compulsive disorder, eating disorders, bipolar disorder, seasonal affective disorder, social anxiety disorder, generalized anxiety disorder, post-traumatic stress disorder, premenstrual dysphoric disorder.

Anticipated Benefit: relief of depression, anxiety, obsessions/compulsions, and symptoms of posttraumatic stress disorder.

Potential side effects Include, but are not limited to: nausea, headache, insomnia or sedation, sexual side effects, increased suicidal thinking, mania (excessively high mood), low sodium level, rash, withdrawal symptoms with abrupt discontinuation, NMS (neuroleptic malignant syndrome: rigidity, fever, unstable vital signs), serotonin syndrome (increased temperature, increased heart rate, shivering, severe twitching), fetal abnormalities if taken in pregnancy.

BUSPAR

Indications: anxiety

Anticipated Benefit: relief from anxiety

Potential side effects Include, but are not limited to: dizziness, drowsiness, nausea, insomnia, headache, restlessness, NMS (neuroleptic malignant syndrome: rigidity, fever, unstable vital signs), serotonin syndrome (increased temperature, increased heart rate, shivering, severe twitching), fetal abnormalities if taken in pregnancy, extra pyramidal symptoms (severe muscle stiffness), tardive dyskinesia (persistent involuntary movements)

TRAZODONE, REMERON

Indications: depression, insomnia

Anticipated Benefit: relief of depression and insomnia

Potential side effects Include, but are not limited to: sedation, nausea, dreams headache, dizziness, sexual dysfunction, appetite changes, blood count, rash, changes, confusion, cardiac changes (blood pressure, arrhythmia), priapism (trazodone), suicidal thinking, mania (excessively high mood), low sodium level, withdrawal symptoms with abrupt discontinuation, NMS (neuroleptic malignant syndrome : rigidity, fever, unstable vital signs), serotonin syndrome (increased temperature, increased heart rate, shivering, severe twitching), Stevens - Johnson syndrome (necrotic rash), fetal abnormalities if taken in pregnancy

TRICYCLIC ANTIDEPRESSANTS: (IMIPRAMINE, AMITRIPTYLINE, NORTRIPTYLINE, DOXEPIN)

Indications: depression, chronic pain, neuropathic pain, post-herpetic neuralgia Anticipated Benefit: relief of depression and pain Potential side effects Include, but are not limited to: drowsiness, dizziness, nausea, confusion, insomnia, restlessness, tremor, libido changes, blood pressure changes, heart arrhythmias, changes in blood counts, suicidal thinking, withdrawal symptoms if stopped abruptly, fetal abnormalities if taken in pregnancy

WELLBUTRIN

Indications: depression, attention deficit hyperactivity disorder

Anticipated Benefit: relief of depression, better impulse control and attention

Potential side effects Include, but are not limited to: headache, agitation, tremor, insomnia, weight loss, anxiety, palpitations, suicidal thinking, mania, blood pressure changes, arrhythmias, rashes including Stevens - Johnson syndrome (necrotic rash), fetal abnormalities if taken in pregnancy.

LITHIUM

Indications: bipolar disorder, depression, mania, schizoaffective disorder, mood instability

Anticipated Benefit: relief of depression, mania and mood instability, decreases suicidal thinking Monitoring: Blood test monitoring Potential side effects Include, but are not limited to: tremor, weight gain, drowsiness, nausea, fatigue, seizures, lithium toxicity (nausea, vomiting, confusion, lethargy, seizures, coma), arrhythmias, thyroid and parathyroid abnormalities, diabetes insipidus (high sodium level, excessive thirst and urination), fetal abnormalities if taken in pregnancy)

SEDATIVE HYPNOTICS: (AMBIEN, KLONOPIN, RESTORIL, VALIUM, XANAX, ATIVAN)

Indications: anxiety, short term treatment of insomnia, seizures, panic disorder, alcohol withdrawal symptoms acutely Anticipated Benefit: relief of anxiety, insomnia, symptoms of acute alcohol withdrawal
Potential side effects Include, but are not limited to: sedation, dizziness, respiratory depression, fatigue, amotivation, confusion, disinhibition, sleep walking, decreased libido, memory problems, incontinence, respiratory failure, addiction, dependency and abuse, seizures, severe withdrawal if stopped quickly, low blood pressure, fainting, fetal abnormalities if taken in pregnancy

MOOD STABILIZERS: (DEPAKOTE, LITHIUM, TEGRETOL, LAMICTAL, NEURONTIN, TRILEPTAL, TOPAMAX)

Indications: bipolar disorder, depression, mania, mood instability, seizures, aggression, impulsivity, migraine headache prophylaxis

Anticipated Benefit: relief of mood swings and mood instability, seizures, aggression and impulsivity Monitoring: Blood test monitoring

Potential side effects Include, but are not limited to: headache, nausea, somnolence, tremor, dizziness, appetite changes or weight changes, memory changes, vision changes, balance problems, blood changes, blood chemistry changes, psychosis, confusion, withdrawal seizures if stopped abruptly, pancreatitis, fetal abnormalities if taken in pregnancy, liver changes and possible liver failure, rashes including Stevens-Johnson Syndrome (necrotic rash)

TYPICAL ANTIPSYCHOTICS: (HALDOL, PROLIXIN, THORAZINE)

Indications: hallucinations, delusions, disorganized thinking, psychosis, acute agitation, schizophrenia, schizoaffective disorder, Tourette syndrome, anxiety

Anticipated Benefit: relief of hallucinations, delusions, disorganized thinking, psychosis, Tourette syndrome or anxiety

Potential side effects Include but are not limited to: extra pyramidal symptoms (severe muscle stiffness), tardive dyskinesia (persistent involuntary movements), restlessness, insomnia, drowsiness or sedation, dry mouth, constipation, weight changes, breast enlargement or discharge, low blood pressure, low blood counts, cardiac changes, NMS (neuroleptic malignant syndrome: rigidity, fever, unstable vital signs), fetal abnormalities if taken in pregnancy.

ATYPICAL ANTIPSYCHOTICS:(ABILIFY, GEODON, INVEGA, RISPERDAL, SEROQUEL, ZYPREXA)

Indications: hallucinations, delusions, disorganized thinking, psychosis, acute agitation, bipolar disorder, treatment resistant major depressive disorder, schizophrenia, schizoaffective disorder.

Anticipated Benefit: relief of hallucinations, delusions, disorganized thinking, acute agitation, symptoms of bipolar disorder, symptoms of depression, symptoms of schizophrenia or symptoms of schizoaffective disorder.

Potential side effects Include, but are not limited to: sedation, increased appetite, insomnia, constipation, weight changes, restlessness, vision changes, extra pyramidal symptoms (severe muscle stiffness), tardive dyskinesia (persistent involuntary movements), breast enlargement or discharge, low blood pressure, low blood counts, cardiac changes, NMS (neuroleptic malignant syndrome: rigidity, fever, unstable vital signs), fetal abnormalities if taken in pregnancy.

CLOZARIL

Indications: hallucinations, delusions, disorganized thinking, psychosis, acute agitation, schizophrenia, schizoaffective disorder, treatment resistant to other medications or history of tardive dyskinesia

Anticipated Benefit: relief of hallucinations, delusions, disorganized thinking, acute agitation, symptoms of schizophrenia or symptoms of schizoaffective disorder

Potential side effects Include, but are not limited to: drowsiness, increased pulse, dizziness, blood pressure changes, tremor, weight gain, restlessness, cardiac changes, agranulocytosis (severely low blood counts), extra pyramidal symptoms (severe muscle stiffness), tardive dyskinesia (persistent involuntary movements), NMS (neuroleptic malignant syndrome: rigidity, fever, unstable vital signs), fetal abnormalities if taken in pregnancy

STIMULANT MEDICATION (ADDERALL, CONCERTA, FOCALIN, RITALIN, VYVANSE,)

Indications: attention deficit hyperactivity disorder

Anticipated Benefit: better impulse control, attention span and decreased activity

Potential side effects Include, but are not limited to: anorexia, insomnia, headache, mood swings, irritability, nervousness, weight changes, diarrhea, agitation, palpitations, increased blood pressure, libido changes, aggression, visual changes, sweating, high abuse, dependency, addiction potential, psychosis, mania, heart attack or arrhythmia, sudden death, stroke, fetal abnormalities if taken in pregnancy, rashes including Stevens-Johnson Syndrome (necrotic rash)

Initials

I have discussed the reason for treatment, the expected outcome and how the treatment will be monitored. I have also discussed the risks and benefits of the medication(s) being prescribed including the possible side effects and the risks associated with not receiving treatment and have discussed possible treatment alternatives with the patient and it is my clinical opinion that the patient understands the information.(Required)

I consent to the use of the psychotherapeutic medication(s) listed above - I understand that although a Concierge Psychiatry, psychiatrists have explained to me the most common side effects of the treatment, there may be other side effects. I will promptly inform the clinic if any unexpected changes in my condition occur.(Required)

I understand that I may not be compelled to take this medication and that I may decide to stop it at any time. However, because abrupt discontinuation could lead to serious side effects or emotional consequences, I agree to discuss the decision first with my doctor.(Required)

I understand that although the psychiatrist believes that this medication will be helpful, there is no guarantee as to the result expected.(Required)

Print Name of Patient(Required)

First Last

Email(Required)

Date

PATIENT/GUARDIAN SIGNATURE