Welcome to the TBI-HELP Live Chat

  Today's topic is: "Psychopharmacological Management of Traumatic Brain Injury Patients"

 Our Guest is: Dr. Glenn Kalash, Coordinator, Inpatient Consultant Liaison Services of Jamaica Hospital Medical Center.

[19:02:26] nmod: Please remember to always check with our own Doctor with regard to all medical and medications that you may be using.
[19:02:46] nmod: Welcome Dr.Kalash.
[19:03:07] DrK: Thank you for having me this evening - it is a pleasure to be here
[19:04:12] nmod: Rail: What is the most commonly prescribed medications for TBI patients?
[19:04:45] DrK: There are a number of medications available but I don't know the #1 medication
  Frequently they include antipsychotics, benzodiazepines, antidepressants. Also, stimulants and hypnotics (for sleep)
[19:05:48] nmod: Dr. Kalash, can you please explain what are antipsychotics?
[19:06:31] DrK: Antipsychotics, also known as neuroleptics, which include the likes of haldol, thorazine and risperdal, work on the dopamine system. They have been most commonly used for schizophrenic and psychotic patients but are often used to control agitation
[19:08:26] nmod: Rail: I know that many medications can mask activities that may be indicators of recovery? What is the general case management priority for medications?
[19:08:57] DrK: Frequently, medications that slow cognition and cause effects such as daytime sedation will often inhibit functional activity. I generally try to avoid those medications with sedative effects since often a TBI patient is often sleepy during the day anyhow
[19:09:45] nmod: Amanda: I find it so strange that when used for TBI some meds have opposite usages, like Ritalin. Used for ADD to calm down and for TBI to get up. I know that meds have multiple uses but these are so opposite.
[19:10:39] DrK: True Amanda, Ritalin is a valuable medication to increase wakefulness, arousal and concentration. Many medications used in psychiatry often have non-FDA uses in TBI patients
[19:12:08] nmod: Rail: I know that many of us don't know about the dopamine system - could you explain briefly?
[19:12:29] DrK: Good point Rail, but trying not to get too technical, here goes... Very basically, in psychosis, we find that there is an over-availability of dopamine. With antipsychotics, also known as dopamine antagonists, they 'block' the receptors, thereby decreasing the amount of dopamine going through the synapse. Dopamine is only one of many neurotransmitters in the brain, including serotoin, norepinephrine, GABA, and acetylcholine
[19:16:48] nmod: Amanda: We also had no idea of our sons abilitis until he was totally weaned off Klonipin. What we thought was a more severe cognitive deficite was sleepiness and lethargy with even a very low dosage. When off totally, speech was not as slurred and unfortunately he didn't require more than 4 hrs. sleep a night. Anyway we would rather have sleepless nights and a more awake son
[19:17:01] DrK: Good issue Amanda...frequently medications that should only be used short-term, get prescribed long-term and have adverse qualitative effects on a persons abilities. If in doubt, especially with a medication with sedative properties, is to wean off slowly and look for a response.
[19:17:43] nmod: Hi Frank: What are some of the problems associated with assessment of TBI patients and medications?
[19:17:48] DrK: Point to be taken : Medications are not everything...sometimes other non-pharmacological modalities are helpful. As a practitioner, I first have to point the finger at the prescribers...many MDs are not aware of the use of psychotropics in brain-injured individuals. Frequently, there are symptoms of disorders that due to aphasia or cognitive impairment that an individual cannot convey. So, one has to look for behavioral manifestations of affective, anxious, psychotic symptoms
[19:20:46] nmod: Rail: On amanda's point - the dopamine blocker reduces the "hyperactivity" in kids; and also reduces the synapse "overload" in TBI patients so they seem to be more in touch??? Is this partly right?
[19:21:43] DrK: In Amanda's case, Ritalin, a 'dopanine agonist' (meaning increases dopamine), it will increase attention and concentration
[19:22:18] DrK: With dopamine-antagonists (decrease dopamine), they will lead to cognitive slowing and decreased attention
[19:22:21] nmod: Amanda: Sometimes inappropriate behavior may be the only means of communicating a TBI survivor may have to suggest there is a problem. Sometimes these are covered up by medicating to conform.
[19:23:36] DrK: Again, point to be taken: Medications should be implemented only when other reversible causes have been ruled-out (such as infections, new CNS problems, metabolic abnormalities) and cognitive-behavioral techniques have been implemented
[19:23:54] nmod: Esmeralda: Do you find that most people are over-medicated?
[19:24:40] DrK: Esmerelda, I don't like to say 'over-medicated' but rather 'inappropriately medicated.' Yes, I believe that many physicians look for a quick fix and give individuals too much medications
[19:25:25] nmod: Jeanette: What are some of the medications that can be used to control behavior for TBI patients that have excessive agressive behaviors?
[19:26:01] DrK: Excellent question Jeanette...there are many factors that go into causing 'aggression'. Some of the modalities include my preference : anticonvulsants (tegretol, depakote, neurontin), but also antidepressants. For the acute course, sometimes antipsychotics and benzodiazepines may be given
[19:27:08] nmod: Hi Melanie: How can you tell if the unwanted effects are from meds or not?
[19:28:20] DrK: Important point Melanie...really the only way is to slowly reduce the medication and see if the side-effects resolve. Also, if in doubt, look at the PDR (but frequently they include every side-effect under the sun)
[19:28:24] nmod: Jeanette: How can we change the medical profession's lack of understanding regarding overmedicating patients?
[19:29:02] DrK: As a medical professional, I am always eager to hear the consumer side. I would like to hear of personal experiences from my patients and their families
[19:30:15] nmod: Amanda: Should a person taking behavior control meds also be getting help with altering the unwanted behavor to have the full benefit of the treatment?
[19:31:49] DrK: In Jamaica Hospital where I work, we have a large department of rehab specialists, including cognitive retrainers and psychologists. I greatly value their input and experience with patients experiencing behavioral dyscontrol. Amanda, I strongly believe in a multi-modality approach
[19:32:50] nmod: Hi AJM: How much misunderstanding is there in the medical community regarding the use of meds and what is considered Right meds?
[19:33:48] DrK: Good question AJM, I'm not sure how to answer that.  I see things from the inside...I think it is helpful for the consumer to educate us too.

[19:35:27] DrK: Please let me remind all our participants that you should talk to your personal physicians regarding your concerns and queries.

[19:36:31] nmod: Esmeralda: Do you find that MDs work with them in a team setting or as support staff? Since most MD's inappropriately medicate there patients, I wold assume they focuse on the medications aspect only
[19:45:43] DrK: Although Esmerelda left the chat room she asks a good question.  I don't think that MD's prescribe inappropriately...they often do their best. We try to work as part of a team and get input from all professionals involved
[19:50:03] nmod: Esmeralda: I find that many DMs think "doing their best" means doing their best to discharge a patients as quickly as they can which usually means patients are without benefit of an effective behavioral therapy plan.. Do you have any comments on this?
[19:50:25] DrK: Esmerelda, it seems that you may have had a bad experience, but this evening I was hoping to focus on the psychopharmacological management of TBI patients
[19:51:03] nmod: Rail: That way the families and caregivers can be sensitive to those medications and a bit pro-active in questioning the dose and duration/
[19:51:37] DrK: Thank you Rail...now any more questions relating to tonights topic?
[19:52:23] nmod: Dr. K: Is there a "best" antidepressant for TBI patients?
[19:53:10] DrK: Today, we are fortunate to a have a wide assortment of safe treatments for depression. To say 'a best one' is not possible, but I generally choose from one of the SSRI's (including Prozac, Zoloft, Celexa or Paxil).  They have minimal side-effects and are well-tolerated
[19:54:52] nmod: Esmeralda: Is the "best" antidepressant for the adult population also the "best" for the pediatric population as well?
[19:55:02] DrK: Unfortunately, Esmerelda, the pediatric population is not well-studied and we often cannot extrapolate to them from the adult population. Medications that have been in use for awhile such as the SSRIs have a good track record.

[19:56:18] nmod: Again, just a reminder that this topic deals with the information about medications and their usual use in TBI cases. This is NOT to be taken as an endorsement or prescription for any of the medications discussed. All medications must be determined by you and your Physician.

[19:57:12] nmod: Esmeralda: Since it is not well-studied, would you say the recovery rate for peds is less than adults/
[19:57:29] DrK: I would not like to be so pessimistic Esmerelda...if depression is identified and an appropriate medication at an appropriate dosage for an appropriate length of time is used, the depression has a good chance of being treated.
[19:57:39] nmod: Amanda: Does depression or aggressiveness get better as brain function improves?
[19:58:44] DrK: Amanda, in general, I see the most significant 'aggression' occurs during the first week to four weeks after the TBI. After that, things will hopefully ameliorate. Depression on the other hand, will only sometimes resolve by itself...it is generally best to actively treat depression with therapy +/- medications
[19:59:49] nmod: Dr. K: Could you give us a list of medications where the family or caregiver should be a bit questioning in the case of TBI patients?
[20:01:29] DrK: In general, I feel that medications such as the benzodiazepines (ativan, xanax, klonopin, valium) and the antipsychotics (such as haldol) should be reserved for short term use. Other medications should be investigated for longer term management.

[20:01:38] nmod: I want to take this opportunity to thank Dr. Kalash for his expert advise and invite him to participate with us again. To all of our audience I wish you all a very happy and healthy holiday season and a wonderful New Year. Good Night
[20:02:05] DrK: Thank you very much for your participation....it was a stimulating evening. I hope to be invited back soon. Good night