The role of pharmacological interventions has been central to the treatment of brain injuries. Medications can help to alleviate pain and physical problems that interfere with daily functioning, as well as help with brain recovery and problems related to social behavior and other performing other complex activities. In combination with Applied Behavior Analysis, pharmacology can be a powerful and effective approach to treating brain injuries.

The use of medications, however, is not without drawbacks and risks.

The following presentation provides relevant information specifically related to the use of medications to treat brain injuries and the complications associated with reducing these medications over time.

Considerations in Psychotropic Medication Reduction After Traumatic Brain Injury

Randall D. Buzan, MD
Associate Professor of Psychiatry
University of Colorado School of Medicine
Consulting Psychiatrist – Learning Services Colorado

Outline of Talk

Good intentions are not enough

Why Reduce Meds?

Anna's Story

Anna is a 40 y.o. DD woman admitted 4-1-09 for “extreme aggression” after beating people up in previous placement. At age 6 she suffered a brain injury and frontal lobe injury and mild MR due to spinal meningitis. She had delayed development and multiple placements due to challenging behavior that included: manipulation, confabulation, perseveration, threats to run away, and severe aggression against self, others, and property.

Previous med trials included Seroquel 1050 mg, Risperidone 11 mg, Klonopin 1.5 mg, haldol 5 mg, Lithium 300 mg, Abilify 10 mg, Depakote 2500 mg, Amantidine 100 mg, Topamax 50 mg, Meridia 5 mg, Paxil 40 mg, Trazodone 100 mg, Geodon and Xanax

Behavioral Intervention

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Who?

Conceivably all patients when:

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What to Taper First?

When to Taper?

Where?

In a setting that can handle a possible decompensation:

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How?

This depends on the drug!

Medications for Depression

Medications for Bipolar Patients

Cognitive Enhancing Agents

Meds for Anxiety Disorders

Tapering drugs for aggression

Not without Risk!

TBI and Aggression

Silver et al APA Textbook of TBI 2005 pp. 259-277

Frontal Inhibition of Aggression

Phineas Gage

A blasting charge sent a 1.5” wide and 3’ long metal spike through his face and frontal lobe

Mr. Gage after his injury

Phineas Gage lost orbitofrontal Cx

Tapering Antipsychotics

Drug side effects include: Rate of taper ideally 10%/month – minimum over 1 month

Withdrawal symptoms can include:

How successful are AP tapers?

Tapering SSRI’s

Half Lives of Psychotropics

Tapering Lithium

Tapering anticonvulsants
(Tegretol/Depakote/Keppra/Neurontin/Lyrica)

Tapering Benzodiazepines+
(Ativan, Xanax, Valium, Klonopin)

Tapering Cognitive/other agents

So, taper meds carefully

Keep your eyes on the patient during the process...

And enjoy your clients and all they can teach on the journey!

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