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Comorbidity of mental disorders and substance use: a brief guide for the primary care clinician

12.6 Does brain injury impact on treatment approaches to mental disorders and substance use?

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• The treatment of mental disorders following brain injury is not well understood.
• It is vital to actively manage mental disorders following brain injury as individuals with postbrain injury history of emotional distress and substance use are the most likely to attempt suicide.
• Sertraline has been shown to be effective in treating depression following brain injury.
• It is important to minimise side effects as brain-injured clients may not have the coping mechanisms to deal with the side effects of psychotropic medications.
• CBT has been shown to be effective in managing acute stress disorder following mild brain injury.
• A level of substance use that may be regarded as 'low risk' in the general population may carry a significantly higher risk for a person who has experienced a brain injury.
• Pharmacotherapy treatments for substance use may also have a variable effect on individuals who have experienced brain injury.

12.6.1 Approaches to substance use

• Individuals need to be counselled on the possible increased risk associated with substance use post-injury.
• It is important to consider the variable cognitive abilities, insight and degree of impulse control when counselling the person who has experienced brain injury^{(512, 514, 516)}. These variables will influence the choice of psychological approaches to the person following brain injury.
• Similarly, pharmacotherapy treatments for substance use may also have a variable effect on individuals who have experienced brain injury due to altered metabolic or neurotransmitter pathways⁽⁵²¹⁾. Pharmacotherapies that may be effective in one individual may not be effective in another who has experienced brain injury.
• As the brain recovers following injury, the effectiveness of pharmacotherapies for substance use and the severity of side effects may change over time within the one individual.
• The sedative effects of benzodiazepines used for acute symptomatic relief during substance withdrawal and opioids such as methadone may be exacerbated in people with brain injury. Therefore, they may increase the risk of overdose^x.

12.6.2 Approaches to mental disorders

• Clinicians need to carefully assess individuals with mental disorders for past history of brain injury⁽⁵⁰⁶⁾. Comorbid brain injury is a frequent problem for people with a mental disorder. Their risk of self harm is higher than for those people without comorbid brain injury.
• People with both a mental disorder and a brain injury may need additional cognitive and psychotherapeutic interventions that are not usually available to people who only have psychiatric diagnoses.
• In a similar fashion to management of individuals with substance use issues following brain injury, pharmacotherapy-based treatments for individuals with mental disorders and brain injury need to be assessed on an individual basis. The risk–benefit balance of drug-based treatments may be quite different in those with brain injury. There may be significant variation from one person to another due to altered metabolic or neurotransmitter pathways⁽⁵²¹⁾.
• In addition, the risk–benefit balance may, in fact, change over time within the individual as the healing process continues and the brain recovers from injury. Therefore, a medication that may have been effective in relieving depressive symptoms immediately following brain injury may not be effective after an extended period of time, or vice versa. This would account for the overall inconsistencies observed in the treatment effectiveness of psychopharmacological drugs following brain injury⁽⁵²³⁾.
• There is also evidence that medications administered to control mental disorders following brain injury may, depending on their mechanisms of action and timing of administration, have a neuroprotective effect. However, they may also slow the recovery process⁽⁵²⁴⁾.
• It is important to minimise side effects as brain-injured clients may not have the coping mechanisms to deal with the side effects of psychotropic medications.
• It is vital to actively manage mental disorders following brain injury as individuals with post-brain injury history of emotional distress and substance use are the most likely to attempt suicide⁽⁵¹⁹⁾. Resolution of depression (whether spontaneous or in response to treatment) following brain injury is accompanied by improvement in psychosocial functioning and perceived enhancement of one's health⁽⁵¹²⁾. Active treatment of depression following brain injury significantly improves emotional functioning and general mental health, physical functioning, sleep and vitality, and social, work and family functioning. Such treatment may also reduce unexplained somatic symptoms, perception of illness severity and disability, and subsequent illness behaviour⁽⁵⁰⁰⁾.
• With doses similar to those used in the general population, sertraline (SSRI) has been shown to be effective in treating depression following brain injury***^{(523, 525, 526)}:
  • Decreases in overall psychological distress have been observed along with minimal side effects***^{(523, 525)}. This is promising, as individuals with brain injury do not usually present with symptoms that fall into strict DSM-IV criteria but with an array of symptoms such as depression and anxiety ^{(519, 525)}.
  • Similarly, sertraline has been shown to significantly decrease the burden of post-concussive symptoms*⁽⁵⁰⁰⁾.
  • If sertraline decreases psychological distress across many domains and minimises the impact of post-concussive syndrome, then it may not be as important to make a strict diagnosis (which may not be possible anyway) following brain injury. In addition, screening for and treating depression in patients with persistent post-concussive symptoms may be an effective way to decrease unnecessary suffering and reduce excess disability⁽⁵⁰⁰⁾.
• The sedative effects of antipsychotics, mood stabilisers, benzodiazepines and sedative antidepressants such as tricyclics may be exacerbated in people with brain injury. Therefore, they may increase the risk of overdose^x.
• CBT has been shown to be effective in managing acute stress disorder following mild brain injury****⁽⁵²⁷⁾. However, the cognitive capacities of the individual need to be considered before undertaking this line of treatment.

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