Pharmaceuticals
Medications for Behavioral Disorders
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Persons with moderate traumatic brain injury often experience a temporary phase of agitation due to confusion. As confusion clears this agitation often resolves. However, some individuals have persistent long-term behavioral problems such as irritability, low frustration tolerance, impulsivity, and verbal or physical aggression. Regardless of the stage of recovery, the first step of behavioral management is to identify and reduce stimuli that may cause agitation. Other strategies for behavioral management include feedback, time out, etc. Should these strategies be unsuccessful, it may then be necessary to use medications to assist in behavioral control. Medications commonly used for behavior can be divided into three major groups: antidepressants, anti-seizure (anticonvulsant) medications, and antipsychotic medications.
There are many different types of antidepressant medications, with the most commonly used class being the selective serotonin reuptake inhibitors (SSRIs). Sertraline (Zoloft), paroxetine (Paxil), citalopram (Celexa), and fluoxetine (Prozac) all fall into the SSRI class. Other types of antidepressants include the older tricyclic antidepressants or “TCAs” and newer agents such as venlafaxine (Effexor), nefazodone (Serzone), and mirtazapine (Remeron). Although no two antidepressants have the exact same effects, in general these medications work by increasing levels of natural brain chemicals (neurotransmitters) such as norepinephrine and serotonin. This initial effect is thought to cause improved efficiency in the brain’s use of these and other neurotransmitters, which gradually results in improved mood and behavior. Often a low to moderate dose of one of these medications can dampen anxiety and irritability enough to allow for better interpersonal reactions.
The next major class of medications used in behavioral control is the anticonvulsant medications. Borrowed from the field of neurology, these agents have been used for years to stabilize psychiatric mood disorders. Using this rationale, some anticonvulsants are also useful in treating mood and impulsivity problems in brain-injured patients. These medications include carbamazepine (Tegretol), valproic acid (Depakote), and lamotrigine (Lamictal), topiramate (Topamax), and many others. Patient responses to these medications tend to be highly individualized; therefore, a trial and error approach must be taken to determine if any single medication will have a positive effect. Like with the antidepressants, effects of these drugs occur gradually, and several weeks of treatment may be needed before response can be determined.
Antipsychotic medications include the newer “atypical” agents risperidone (Risperdal), olanzapine (Zyprexa), quetiapine (Seroquel), ziprasidone (Geodon), as well as many other older “typical” agents such as haloperidol (Haldol) and chlorpromazine (Thorazine). “Atypical” antipsychotics are overall safer and much better tolerated than older typical agents. Antipsychotics can be used to treat severe behavioral and thought disorders in brain injured persons. Thought disorders may include delusions (false beliefs) and hallucinations (abnormal sensory perceptions). These medications are fairly quick-acting but are typically reserved for persons whose behavior is dangerous.
In summary, there are situations where medications may be necessary to lessen maladaptive behaviors and improve interpersonal relations. Medication selection should be guided by potential side effects, especially those which may further impair cognition (thinking ability) or mobility (walking, transfers, etc.). It is important for the patient and/or their caregiver to know which specific behaviors the medication is being used to treat, how long before response is expected, common side effects of the medication, and whether there are any symptoms to watch out for that may signal a serious side effect.
Alan M. Harben, MD, PhD is a Fellow of the American Academy of Physical Medicine and Rehabilitation and has completed doctoral training in the field of Biomechanics. He is Medical Director of the Restore Neurobehavioral Center located in Roswell, Georgia, a rehabilitation program for persons with behavioral disorders due to acquired brain injury. He also serves as the medical consultant for The Bridge, an adolescent psychiatric program located in Atlanta, Georgia. He is a past Chair of the Brain Injury Resource Foundation. His private practice in Roswell, Georgia specializes in neurological and musculoskeletal rehabilitation.
Sara Grimsley Augustin, Pharm.D. and Board-Certified Psychiatric Pharmacist (BCPP), is on faculty at Mercer University Southern School of Pharmacy in Atlanta, GA, where she teaches in the areas of psychiatry, neurology, and substance abuse. Dr. Augustin has provided consultant pharmacy services to Restore Neurobehavioral Program since 1992 and has worked with this program to optimize outcomes in neurobehavioral pharmacotherapy.