TOOL 6.2: General Considerations Regarding Pharmacotherapy
- Address significant psycho-social stressors before starting treatment (Heads Up Checkup: Mental Health and Behavioral Risk Screening System).
- Review current medications, including over-the-counter medicines and supplements, before starting treatment. If possible, minimize or withdraw agents that may exacerbate or maintain symptoms. Screen for overmedication headaches.
- Ideally a psychiatrist would be involved in the prescribing of psychotropic medication but an experienced family doctor or pediatrician, may initiate and monitor treatment. In severe cases, a psychiatrist should be consulted.
- Change only one medication at a time.
- Target drug therapy to specific symptoms (example: dysphoria, anxiety, mood swings, irritability, fatigue, sleep, headache and pain), and monitor during the course of treatment.
- Consider waiting until 12 weeks before starting a mood-altering medication unless the clinical scenario dictates otherwise.
- Choose therapies that minimize the impact of adverse effects on awakening, cognition, sleep and motor coordination, as well as on seizure threshold-domains in which children/adolescents with concussion may already be compromised.
- Start at the lowest effective dose and titrate slowly upwards, monitoring tolerability and clinical response, and also aiming for adequate dose and duration. Treatment often fails because either are insufficient. At times, you may have to prescribe the maximum tolerated doses.
- Aim to use a single agent to alleviate several symptoms. However, as individual symptoms may not show a coupled response to treatment, you may have to try a combination of strategies.
- Offer limited quantities of medications to those at a higher risk of suicide.
- Continue successful pharmacotherapy for at least 6 months, preferably 9 to 12 months for SSRIs, before tapering off on a trial basis.
- Use a specific SSRI as first-line treatment for mood and anxiety syndromes. Avoid using benzodiazepines as first-line therapy for anxiety. Avoid opiates.
- Follow-up regularly.
Adapted from Silver JM, Arcinigas DB, Yudosky SC. Psychopharmacology. In: Silver JM, Arciniegas DB, Yudovsky SC, eds. Adapted with permission from the Textbook of Traumatic Brain Injury, (Copyright ©2005). American Psychiatric Association. All Rights Reserved.