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Traumatic brain injury (TBI) is a common phenomenon. Patients who have experienced an injury of this type can develop a range of psychiatric conditions [including depression, bipolar disorder, secondary mania, psychotic states (schizophreniform and paranoid), post-traumatic stress disorder, obsessive-compulsive disorder, phobic disorders, panic disorder and generalised anxiety disorder] and neuropsychiatric syndromes (including apathetic states and disorders of impulse control, ranging from irritability to severe aggression). Despite the prevalence of these conditions, there have been no adequately controlled studies of epidemiology or pharmacological interventions. Hence, treatment approaches generally follow those seen in psychiatric conditions that occur in non-TBI populations. However, adjustments in these approaches must be made to account for the adverse effect profiles of the drugs used that may worsen cognitive function. Medications with prominent anticholinergic, anti-histaminergic or antidopaminergic effects should therefore not be used as first-line interventions. In addition, traditional antipsychotics may block synaptic plasticity and so should be used with caution in patients with TBI. The management of apathetic syndromes is based on a paradigm of elevating dopaminergic (with or without noradrenergic) activity. Treatment of impulse control disorders centres on increasing serotonergic activity, along with the use of β-blockers (which may act through serotonin receptors) and anticonvulsants. Stimulant medications can also be useful for apathetic syndromes, and may enhance synaptic plasticity. While this review predominantly discusses pharmacological interventions, they are only part of the essential multi-disciplinary management of patients with TBI. Cognitive, behavioural and family interventions should also be applied. Environmental management is often paramount, as the environment is frequently easier to alter than the disorders in the individual with TBI are to treat. |
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