Twenty Years of Pharmacology

Update on Insomnia after Mild Traumatic Brain Injury

Sleep disturbance after traumatic brain injury (TBI) has received growing interest in recent years, garnering many publications. Insomnia is highly prevalent within the mild traumatic brain injury (mTBI) population and is a subtle, frequently persistent complaint that often goes undiagnosed. For individuals with mTBI, problems with sleep can compromise the recovery process and impede social reintegration. This article updates the evidence on etiology, epidemiology, prognosis, consequences, differential diagnosis, and treatment of insomnia in the context of mild TBI. This article aims to increase awareness about insomnia following mTBI in the hopes that it may improve diagnosis, evaluation, and treatment of sleeping disturbance in this population while revealing areas for future research.

Emerging therapies in neurorehabilitation

Just as advancing technology has furthered our understanding of how the nervous system recovers, technology also enables the development of novel approaches to treatment. Because nervous system disease and injury often lead to severely impaired function, patients and families are willing to try anything, so therapies are often adopted with little evidence that they actually work. Evidence shows that comprehensive rehabilitation programs produce better outcomes, but it is still not understood what components of these multifaceted programs are critical to their success. Functional neuroimaging and other modalities now allow monitoring of neurophysiologic changes that can be paired with assessments detailing clinical changes, furthering our understanding of the factors that influence the recovery process. This article discusses several novel and emerging therapies in neurorehabilitation as well as recent multistudy reviews of selected treatments.

A randomized controlled trial of sertraline for the treatment of depression in persons with traumatic brain injury

OBJECTIVE

To examine the efficacy of sertraline in the treatment of depression after traumatic brain injury (TBI).

DESIGN

Double-blind, randomized controlled trial.

SETTING

Research center at a major urban medical center.

PARTICIPANTS

Subjects were a referred and volunteer sample of 52 participants with TBI, a diagnosis of major depression disorder (MDD), and a score on the Hamilton Rating Scale for Depression (HAM-D) of 18 or greater. The majority of the sample was male (58%), had less than 14 years of education (73%), had incomes below $20,000 (82%), and were from minority backgrounds (75%). Approximately one third of the sample had mild brain injuries, and two thirds had moderate to severe brain injuries. The mean age was 47+/-11, and the mean time since injury was 17+/-14 years. One participant withdrew from the study because of side effects.

INTERVENTION

Daily oral sertraline in doses starting at 25mg and increasing to therapeutic levels (up to 200mg) or placebo for 10 weeks.

MAIN OUTCOME MEASURES

The HAM-D, the Beck Anxiety Inventory, and the Life-3 quality of life (QOL).

RESULTS

No statistically significant differences were found at baseline between drug and placebo groups on baseline measures of depression (24.8+/-7.3 vs 27.7+/-7.0), anxiety (16.4+/-12.3 vs 24.0+/-14.9), or QOL (2.96+/-1.0 vs 2.9+/-0.9). The income level of those receiving placebo was significantly lower than those participants receiving medication. Analyses of covariance revealed significant changes from preintervention to posttreatment for all 3 outcome measures (P<.001) but no group effects. Random-effects modeling did not find any significant difference in patterns of scores of the outcome measures between the placebo and medication groups.

CONCLUSIONS

Both groups showed improvements in mood, anxiety, and QOL, with 59% of the experimental group and 32% of the placebo group responding to the treatment, defined as a reduction of a person's HAM-D score by 50%.

A review of pharmacological treatments used in experimental models of traumatic brain injury

PRIMARY OBJECTIVE

We provide a review of recent chronic and delayed rehabilitative pharmacological treatments examined in experimental models of traumatic brain injury. There is a specific emphasis on studies aiming to enhance cognitive recovery.

MAIN OUTCOMES AND RESULTS

Decreased neuronal activity is believed to contribute to persistent cognitive disabilities. Neurotransmitter based rehabilitative treatments that increase neuronal activity may assist in the recovery of cognitive function. However, timing and dosage of drug treatment are influential in cognitive enhancement. Drug treatments that affect single and multiple neurotransmitter systems have the ability to significantly influence recovery of function following brain injury.

CONCLUSIONS

Understanding the relationship between neural disturbances and functional deficits following brain injury is challenging. Cognitive impairment may be the result of a single event or multiple events that occur after the initial insult. Increasing neuronal activity during the chronic phase of injury seems to be an effective treatment strategy for facilitating cognitive recovery. Pharmacological agents do not necessarily display the same effects in an injured brain as in a non-injured brain. Thus, further research is needed to establish the effectiveness of rehabilitative drug treatments.

Pharmacological enhancement of cognitive and behavioral deficits after traumatic brain injury

PURPOSE OF REVIEW

To provide the clinician with a reasonable overview of the modern pharmacological alternatives to treat the cognitive and behavioral sequels of traumatic brain injury.

RECENT FINDINGS

Original research in this area is sparse and more than half of the articles published on the subject recently have been reviews. Of the three randomized controlled trials, one studied methylphenidate (n = 18), one methylphenidate and sertraline (n = 30) and one amantadine (n = 27). All these studies reported beneficial effects on various cognitive measures, but because of the study protocols, the evidence provided may be questioned. The various reviews, uncontrolled studies and case reports suggest that at least psychostimulants, cholinergic agents, dopaminergic agents and antidepressants may be beneficial in treating the cognitive and behavioral symptoms of traumatic brain injury.

SUMMARY

The clinician trying to ameliorate the cognitive and behavioral symptoms of traumatic brain injury has to make decisions about pharmacotherapy that are still based mainly on clinical experience. Large randomized controlled trials giving high-quality evidence are so far missing. This review discusses the problems facing both the clinician and the scientist treating the cognitive and behavioral sequels of traumatic brain injury. A symptom-based approach is suggested for current practice.