Medications

QUESTION:

I have a relative who sustained a brain injury in a car accident. Since the accident, he has been very depressed. The counselor he sees confirms that he is "clinically depressed" and recommends consulting a psychiatrist. I am wondering if the brain injury caused this depression or if my family member is just depressed because his life circumstances have changed since the accident. Also, what treatment might a psychiatrist recommend (e.g., are there prescription drugs that are commonly used to treat depression after brain injury)?

ANSWER #1:

The use of Prozac or other antidepressants following brain injury can be a useful adjunct to routine neurorehabilitation. Antidepressants work by increasing neurotransmitters (the chemical messengers that allow nerve cells to communicate one to another) to return to more normal levels. Studies over the past several decades have shown decreases in neurotransmitters following all severities of traumatic brain injuries. Antidepressants through their interference with typical breakdown of neurotransmitters can increase the levels to more normal ranges. Decreases in neural transmitters are presumably the underlying change that results in difficulties with mood, concentration, and initiation. Certainly, a depressive symptom complex can be triggered by organic or physical brain changes which influences those regions of the brain responsible for mood regulation. The use of Prozac or other antidepressants may in fact be beneficial to improving outcome as has been demonstrated in numerous studies of individuals with strokes. Improvement in these symptoms through the use of an antidepressant does not at all indicate that they are imaginary. Quite the contrary, a positive response to antidepressants does indicate an underlying neurochemical change.

ANSWER #2:

There is not enough evidence or data to point to causation. It is clear that with brain injury, as with many other medical conditions, there is a higher prevalence of "clinical depression" than would be expected in the general population. It also needs to be clarified what is meant by clinical depression. There is a whole spectrum of depressive illnesses as defined in the DSM IV (Diagnostic & Statistical Manual of mental illness, 4th edition), and each of those depressive illnesses responds to somewhat different treatments. One of the most serious forms of depression is called "major depression" and is typified by at least a two-week period of feeling sad/depressed or apathetic, accompanied by four or more of the following symptoms:

significant weight change (5% or more in a month)
insomnia or sleeping too much
motor agitation or slowing observed by others
fatigue or loss of energy
feelings of worthlessness
decreased concentration or indecisiveness
recurrent thoughts of death or suicidal thoughts

It is important to make sure that this is not occurring in the face of acute grieving or mourning, because the treatment would be different. It is also important to rule out obvious physical problems or medications that could be contributing to depressive symptoms including illicit drugs and alcohol. Regardless, a depressive episode of this magnitude needs serious attention, including psychiatric consultation.

The best treatment for major depression is a combination of counseling and medications. The counseling and medications vary some with the psychiatrist. The most commonly used antidepressants for patients with major depression after brain injury are the same used in patients with major depression without brain injury, and they include: fluoxetine hydrochloride (Prozac), sertraline (Zoloft), paroxetine (Paxil), fluvoxamine (Luvox), nefazadone (Serzone), venlafaxine, (Effexor), desipramine (Norpramin), nortriptyline (Pamelor), bupropion, (Wellbutrin), imipramine (Tofranil) and amitriptyline (Elavil). I do not feel that Ritalin is an adequate medication for major depression.

These medications are probably equally effective, but their real differences lie in the side effects. I generally start with the antidepressants that are the least sedating (such as Prozac, Paxil, Zoloft, Norpramine, and Wellbutrin) so as not to worsen any cognitive dysfunction. Other than that, it then turns into a situation of hit and miss. I would generally expect an antidepressant (at adequate dose) to start to show some effects by three to four weeks, and if the patient has had absolutely no positive response by that time I might move to another medication. It can take as long as six to eight weeks for the medication to reach its full effects.

An additional issue is seizure risk. Depending on the type of brain injury there are increasing risks of seizures. All of the antidepressants probably increase the risk of seizure, but for the most part this risk is minimal, especially compared to the risk of not treating a major depression adequately. The only antidepressant that I listed that seems to have a slightly higher risk of seizure is bupropion (Wellbutrin) but even so, the risk is only 3-4% compared to the other antidepressants at about 1%. So if a patient has developed post-traumatic seizures, I would make sure that the patient's seizure medication was at adequate levels in consultation with the neurologist before I started an antidepressant (especially Wellbutrin, but it would not prevent me from using the antidepressant).

One additional factor is that in general, I use lower doses of antidepressants because an injured brain is probably going to be more sensitive to the effects and side effects of the medication. Once a patient is stable on an antidepressant I would leave him/her on the medication for at least six months to one year, unless the patient had had several previous major depressive episodes, in which case I might recommend more indefinite use.

QUESTION:

My son has been referred to a psychiatrist for help controlling behavior problems related to a brain injury. He has not been able to lead a normal life since the injury due to mood swings, periods of depression, and angry outbursts that scare the family. My son has an overall lack of self-control that compromises his ability to interact socially and live independently. What should we expect in the way of assistance from the psychiatrist? Is it reasonable to expect drugs to control behavior problems after brain injury?

ANSWER #1:

Psychiatric intervention for individuals following traumatic brain injury can be helpful in those situations where impulse control difficulties prevent academic, vocational or social success. Psychiatric or neuropsychiatric intervention is not designed to control the "individual" but rather to correct the underlying brain chemical (neurotransmitter) alterations that have been well described to occur following brain injury. These medications are intended to return the brain environment to the relative amounts of neurotransmitters which will assist the patient in regaining appropriate behavioral controls. The use of medications exclusively should be avoided. A better approach would be the combination of appropriate pharmacological intervention and behavioral/psychotherapeutic intervention to assist the individual in adapting to his residual neurologic impairment.

ANSWER # 2:

Problems with mood swings are common after brain injury. These usually take the form of periods of sadness, as well as irritability. There are several medications that may significantly alleviate this problem. Before a medication is prescribed by a psychiatrist, he/she should review your son's problems, including other difficulties he may be having. Many individuals after brain injury may be on several medications. These may have side effects, including depression and irritability. If possible, these medications may be changed or discontinued if not still necessary. Other emotional symptoms may guide the choice of medication.

Medications that can be very helpful include antidepressants such as sertraline (Zoloft) and fluoxetine (Prozac), mood stabilizers such as valproic acid (Depakote), and several others. There are several important guidelines that should be followed. Medications, in general, should be started gradually, as individuals with brain injury are more sensitive to side effects than are those without brain injury. When a medication is prescribed, it is important that it be given a chance to work (what is called a "therapeutic trial"). This includes time on the medication and the dose administered.

Medications will improve emotional control and decrease depression and irritability. But remember that medications are not a "cure," and that other therapies are still necessary.

QUESTION:

What is emotional lability? Are there prescription drugs to treat it?

ANSWER:

Emotional lability refers to sudden, often frequent, and unexpected mood changes that can occur after brain injury but is not solely related to brain injury. It has probably been most formally studied in post-stroke patients and is also referred to as "emotional incontinence." In its milder forms, it can be seen as more irritability but in its more severe forms can require formal treatment. Rarely, it is part of a seizure disorder. When the main emotional manifestation is crying, the patient needs to be further evaluated for a clinical depression. Other psychiatric conditions that involve emotional lability are manic depression (Bipolar illness), delirium, and dementia. The most commonly used medications are antidepressants, but other medications include buspirone (Buspar), carbamazepine (Tegretol), valproate (Depakote or Depakene), as well as benzodiazapines and antipsychotics. There is no good consensus about length of treatment, but once the lability is under control, a trial at weaning the patient off the medication is not unreasonable to see if the symptoms return. Additionally, behavioral treatments can also be quite effective.