We are happy to share the second post in a series of three from our founder and Senior Medical Officer, Dr. Nathan Cope. Be sure to read part 1 if you missed it. – Dr. Holt
In my post last week, I discussed the general neuropsychiatric overview of TBI as well as the approach to the cognitive and emotional impairments following mild TBI injuries. This week I will discuss the consequences of more severe TBIs and address the role of psychopharmacology in the treatment of such injuries.
Recall that these moderate and severe injuries make up less than 15% of the total incidence of TBI in the United States, but produce the vast majority of long-term, TBI-related disability. Millions of Americans are living with the long-term deficits resulting from these more serious injuries. For many of these survivors, various psychiatric issues emerge. These issues can be addressed via environmental and psychotherapeutic approaches, as well as psychopharmacological approaches.
Consequences of Moderate and Severe TBI
As with any TBI, there is an immediate period of disorder or loss of consciousness. Additionally, with moderate and severe TBI, there is a wide spectrum of syndromes which can occur. For example, for injuries that involve the lower brain areas (brainstem), multiple hard neurologic deficits are commonly seen: difficulty with temperature and blood pressure regulation, reduced function of vital processes such as respiratory drive, difficulty with arousal, reduced autonomic functioning, severe paralysis (locked-in syndrome) and so forth.
With such cases, it can be difficult to ascertain whether beneath the “unresponsive” patient there is an individual who is aware but unable to move or communicate. This is a difficult clinical issue–how do we ever really know that there is not awareness that we as physicians cannot observe? There are also cases where significant error has been made and patients do have awareness that is not appreciated. Moreover, if the patient is sedated with drugs or is significantly ill from another cause (e.g. infection or metabolic disturbance) then an error can be made about the ultimate potential for recovery and awareness. It is important to ensure a sufficient period of expert clinical observation and trial to observe for any sign of awareness.
During this period, the principle psychiatric task is to accurately understand the neurologic damage and prognosis and communicate this to the family of the patient. There is a tremendous psychological “crisis” in this acute injury period which can lead families to form erroneous or maladaptive beliefs leading to much needless treatment and distress. Early efforts to fully educate and counsel families in this early period will be multiple times more effective than similar efforts delayed.
Return to Consciousness and Psychopharmacology
In most cases, even with the most severe TBI, responsiveness eventually returns. Initially, there is usually a period of acute agitation and confusion (delirium). As noted last week, psychoactive medication is rarely needed during this period and treatment should include simple measures to protect the patient from self injury. Only in special circumstances, such as if there are medical I.V. lines or other measures which require a quieter patient, would it be appropriate to use a simple sedative or narcotic to produce calm, and these should be discontinued as soon as medically possible.
In general, pharmacologic treatment is felt to be a later (if not last) resort intervention; to be ventured after inadequate response to more general rehabilitation efforts involving traditional physical, occupation, speech and psychological therapies. No drugs have been validated with large-scale prospective, randomized, blind studies, despite a variety of pharmacologic approaches that have been reported effective to some degree. Nevertheless, the most common classes of drugs indicted as useful following TBI include almost the entire range of psychotherapeutic agents: neuroleptics (antipsychotics), anticonvulsants, mood stabilizers, stimulants, antidepressants and antianxiety agents.
Only under some circumstances is pharmacologic treatment appropriate. For example, it may be important to gain immediate behavioral control of a manically excited or aggressive patient, or it may be felt that a combination of stimulant and traditional therapies is a more efficient way to benefit from limited rehabilitation resources (i.e. limited acute rehabilitation hospital days).
In any case, it is essential when using drugs that good single-case design be followed:
- make good baseline measurements of the specific behavior or mood to be effected
- trial a specific drug at both an adequate dose and for an adequate duration
- follow the rule of “start low and go slow”
- keep specific periodic measures of response to demonstrate change (or lack thereof)
- conduct a drug withdrawal phase to see if the target behavior recurs
- reinstitute the drug when efficacy has been demonstrated by the above procedure
- design a follow-up plan to periodically reevaluate the necessity of the medication
I’d like to emphasize the importance of that last point. Too often, when a drug is found to be therapeutic in the short term (and unfortunately often even when it is not), the drug regimen is continued on “automatic pilot” without reestablishing the need or benefit. All psychoactive drugs have significant side effects and toxicities, including elevated mortality, which have generally been shown to be more a risk with patients with organic conditions of the brain (e.g. TBI).
It is best for a physician with specific training and experience in the treatment of TBI (usually a psychiatrist, behavioral neurologist or a rehabilitation specialist) to manage the psychopharmacologic approach to TBI.
Continued Recovery, Cognitive Disturbance, and Psychotherapeutic Counseling
As a TBI patient continues to recover, more specific, non-psychopharmacologic strategies may be appropriate. I’ll discuss this in more detail in my third and final post next week.