Biological Perspectives Traumatic Brain Injury—War Related: Part II

I n Part I of this two-part series, the pathophysiology, symptoms, and behavioral sequelae of war-related traumatic brain injury (TBI) were discussed. This issue’s column focuses on therapies. A multidisciplinary approach integrating physical/occupational therapy, speech/audiology evaluation and therapy, orthopedic and general medical care, case management, and psychological/cognitive therapies is generally recommended (Koponen et al., 2002; Lee, Lyketsos, & Rao, 2003; Okie, 2006). This column will focus more narrowly on the psychopharmacological treatment of TBI’s neurobehavioral consequences. The challenges in administering this treatment will also be discussed. Before a specific case example is revisited, a general review of some guiding principles in the medication management of TBI will be useful. Because traumatic brain injury is such an individual insult, there is great heterogeneity in therapeutic response to any specific agent. While one veteran may show great improvement from a certain class of medications, a veteran with a seemingly similar injury could manifest quite the opposite response (Tenovuo, 2006). Another paradoxical biological treatment issue concerns the sensitivity to medications after TBI. Some patients, possibly due to neurochemical changes occurring in the postinjured brain, are exquisitely sensitive to the effects of prescription drugs (Ashman, Gordon, Cantor, & Hibbard, 2006; Tenovuo, 2006). Some experts recommend starting with low, possibly even subtherapeutic dosages and undertaking a very gradual titration in order to monitor for appearance of side effects (Ashman et al.; Lee et al., 2003; Warden et al., 2006). On the opposite side are those post-TBI patients who show little improvement with standard dosages of medications (Tenovuo, 2006). It is essentially impossible to identify in advance which situation will occur with an individual patient, leaving the prescribing clinician with a “trial-and-error” approach in many cases. When higher dosages are required, the lag time in reaching the therapeutic dosage thus increases. Three panels of leading researchers in the field of brain injury recently convened, with the goal of developing consensus guidelines for biological treatment of TBI. They performed an exhaustive literature review, and despite the examination of virtually all the relevant studies, no standards and few guidelines could be recommended (Warden et al., 2006). The following discussion utilizes psychopharmacological guidelines and suggestions as set forth by this panel, as well as by earlier work. The level of evidence for each medication intervention is also mentioned.