THE AFTERMATH OF WAR
Traumatic Brain Injury Among Veterans Returning From Afghanistan and Iraq
Strategies for Diagnosis and Treatment
By Bruce Capehart, MD, MBA and Dale Bass, PhD |
July 13, 2011
Dr Capehart is Medical Director of the OEF/OIF program at the VA Medical Center in Durham, NC, and Assistant Professor in the department of psychiatry and behavioral sciences at Duke University School of Medicine in Durham, NC. Dr Bass is Associate Research Professor in the department of biomedical engineering at the Pratt School of Engineering, Duke University.
Substance abuse is another consideration when prescribing stimulant medication, because both clinical and medicolegal issues exist. Some patients with TBI may benefit from stimulant medication despite the presence of substance abuse. Neuropsychological testing can help establish which patients may benefit from stimulant medication. If the patient participates in a substance use program and demonstrates progress toward substance use recovery, then a stimulant medication may be an appropriate option. Close cooperation with the substance use disorder clinician or team is highly recommended; periodic urine drug screens also are appropriate. The overall clinical goal should be to promote better cognition through substance abstinence and, if necessary, stimulant medication. A substance use disorder diagnosis by itself should not prevent appropriate medical therapy for impaired cognition if the patient demonstrates a willingness to participate in substance use treatment.
State and/or local medical practice regulations may provide additional guidance on prescribing a controlled substance for patients with known substance use disorders. Psychiatrists in this clinical situation may wish to review the pertinent medical practice laws or regulations, consult with the state medical or pharmacy board, or seek advice from the hospital or clinic attorney.
Medical diagnosis begins with recognizing the epidemiological setting in which a patient presents. The combat veteran returns home from an occupational environment that presented physical, moral, emotional, and existential challenges that can only be imagined by most mental health clinicians. While psychiatrists are familiar with the possible diagnosis of a postcombat mood or anxiety condition, most medical education includes little exposure to brain injuries, and the natural tendency is to think PTSD when hearing “insomnia, irritability, and vague depressive symptoms.” This reaction often will be correct in combat veterans. However, the presence of PTSD or major depression does not rule out the presence of TBI.
Among veterans of Afghanistan and Iraq, estimates of TBI prevalence range from 8% to 23%, and TBI must be considered as a possible comorbid condition.19 When the psychiatrist working with combat veterans finds either an atypical symptom cluster or an Axis I condition that does not respond to usual interventions, the wise choice is to consider TBI as an alternative or comorbid diagnosis.
Making an accurate TBI diagnosis in a combat veteran includes obtaining a history of past head injuries, including those injuries not considered significant by the veteran; performing a careful clinical assessment of psychiatric symptoms; possibly referring for neuropsychological testing; and providing symptom-focused treatment. Appropriate treatment can result in significant clinical benefit for the veteran.
Also in this Special Report
Dr Capehart reports that he is listed as the sole inventor on a patent application describing tizanidine for the treatment of certain psychiatric disorders. This patent is owned by the federal government and there are no current licensing agreements with this patent. Dr Bass reports that he has no conflicts of interest concerning the subject matter of this article.
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