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What Can a Pill D o F or Y ou?

What Can a Pill D o F or Y ou?. A Guide T o the Use O f M edications In B rain Injury Katherine Browlowe , MD Psychiatrist, Rutland Regional Medical Center. Disclosures.

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What Can a Pill D o F or Y ou?

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  1. What Can a Pill Do For You? A Guide To the Use Of Medications In Brain Injury Katherine Browlowe, MD Psychiatrist, Rutland Regional Medical Center

  2. Disclosures • I do not have any financial relationship with any pharmaceutical company, device manufacturer, or anyone else with a financial interest in this topic • This talk discusses off-label uses of medications • I may be a doctor but I am most likely not YOUR doctor. Please discuss these issues with your medical caregivers

  3. Traumatic Brain Injury • Affects 1.7 million in US annually • Contributes to 1/3 of injury deaths in the US • Male > Female • High rates in ages 0-4, 15-19, and over 65 • Costs (medical plus lost productivity) = $76.5 billion annually • VT TBI Needs/Resource Survey VT has similar statistics to national averages

  4. TBI

  5. Factors Affecting Recovery • Severity of injury • Location of injury • Age of injured person • Past TBIs • Post-injury treatment • Substance use • Other medical complications

  6. Common Post-TBI issues • Cognitive function • Memory, concentration, attention, executive function, apathy • Emotional function • Depression, mania • Anxiety • Personality change • Impulsivity, anger • “Emotional incontinence”

  7. Treatments • Physical Therapy • Occupational Therapy • Speech Therapy • Cognitive Rehab • Psychotherapy • Medical management • Co-morbid illness • Neuropsychiatric issues

  8. Med Groups • Antidepressants • Antipsychotics • Mood stabilizers • Stimulants • Cognitive Enhancers • Anti-anxiety • “Anti-PTSD” • Beta blockers, alpha blockers

  9. Depression • 33% of patients with TBI have depression within 1 year • Risk factors • Prior mood/anxiety problems, impaired social function, left-sided brain injury • Higher rates of anxiety and aggression co-occurring • Associated with worse cognitive impairment • Can be difficult to diagnose • Exclude medical cause • Communication limitations

  10. Depression • Caregivers are also at risk of developing depression • Monitoring for treatment needs in caregivers is vital to manage health of the patient’s healthcare system

  11. Antidepressants • SSRIs • Sertraline (Zoloft), citalopram (Celexa) • TCAs • Desipramine (one small study) • Augmentation with stimulants • Dextroamphetamine (Adderall), methylphenidate (Ritalin, Concerta)

  12. Antidepressant Benefits • SSRIs usually well-tolerated • Minimal risks • Reduce irritability • Decrease anxiety • Improve engagement with treatment

  13. Antidepressant Challenges • 4-6 weeks to take effect • Non-SSRIs have problematic side effects • Ex. seizure risk with TCAs, bupropion (Wellbutrin) • Minimal data on effects • One study showed 59% of pts with response to med vs. 32% placebo response • TBI patients more sensitive to side effects

  14. Psychosis

  15. Behavioral Issues • Aggression • Impulsivity • Anger

  16. Antipsychotics

  17. Unstable Mood

  18. Mood Stabilizers

  19. Impaired Cognition

  20. Stimulants

  21. Cognitive Enhancers

  22. Anxiety

  23. PTSD

  24. References • CDC report on Traumatic Brain Injury http://www.cdc.gov/traumaticbraininjury/statistics.html • State of VT Needs Assessment of the needs of TBI patients and their families http://www.ddas.vermont.gov/ddas-publications/pub-tbi/publications-tbi-documents/tbi-2003-needs-assessment-report • Treating Depression Following Traumatic Brain Injury http://www.msktc.org/lib/docs/TBI_Depression_Clinical_Summary.pdf http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2864457/

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