Neuropsychiatric sequelae of stroke and traumatic brain injury: the role of psychostimulants

Methylphenidate augmentation of escitalopram to enhance adherence to antidepressant treatment: a pilot randomized controlled trial

BACKGROUND

Adherence to treatment, i.e. the extent to which a patient's therapeutic engagement coincides with the prescribed treatment, is among the most important problems in mental health care. The current study investigated the influence of pairing an acute positive reinforcing dopaminergic/noradrenergic effect (methylphenidate, MPH) with a standard antidepressant on the rates of adherence to medication treatment. The primary objective of this study was to determine whether MPH + escitalopram resulted in higher rates of medication adherence relative to placebo + escitalopram.

METHODS

Twenty participants with moderate to severe depression were 1-1 randomized to either (1) 5 mg MPH + 10 mg escitalopram or (2) placebo + 10 mg escitalopram with the possibility for a dose increase at 4 weeks. A Bayesian analysis was conducted to evaluate the outcomes.

RESULTS

First, neither percent Pill count nor Medication Electronic Monitoring System adherence showed that MPH was superior to placebo. In fact, placebo showed slightly higher adherence rates on the primary (7.82% better than MPH) and secondary (7.07% better than MPH) outcomes. There was a less than 25% chance of MPH augmentation showing at least as good or better adherence than placebo. Second, both groups showed a significant effect of treatment on the QIDS-SR with a median effect of an 8.6-point score reduction. Third, neither subjective measures of adherence attitudes nor socio-demographic covariates had a significant influence on the primary or secondary outcome variables.

CONCLUSIONS

These data do not support the use of MPH to increase adherence to antidepressant medication in individuals with moderate to severe depression. CLINICALTRIALS.

GOV IDENTIFIER

NCT03388164 , registered on 01/02/2018.

The effectiveness of methylphenidate in improving cognition after brain injury in adults: a systematic review

Objective: To conduct a systematic review investigating the effectiveness of methylphenidate in improving cognition following brain injury in an adult population.Data sources: CINAHL, PsychINFO, MEDLINE, and PubMed databases were searched for all relevant articles published from January 1980 up to December 2017.Study selection: Studies were included if participants had a diagnosis of new onset or previous acquired brain injury and were age 16 or over. Studies must have administered methylphenidate and measured its effectiveness on cognition using at least one measure of cognitive function.Data extraction: Data extracted included study design, sample size, participant characteristics, intervention method, outcome measures, and findings. The quality of included randomized controlled trials was assessed using the Physiotherapy Evidence Database. An overall level of evidence was assigned using a modified Sackett scale.Data synthesis: Included studies consisted of seven randomized controlled trials, two pre-post trials, one prospective controlled trial, and one case study. All included studies reported improved cognitive abilities following methylphenidate treatment post-injury.Conclusions: There is the strongest level of evidence (Level 1a) suggesting methylphenidate may alleviate cognitive impairments in adults with brain injury. However, longitudinal studies are warranted examining the effectiveness and safety of long-term methylphenidate use in this population.

Beyond ADHD and narcolepsy: psychostimulants in general psychiatry

Psychostimulants (dexamphetamine, methylphenidate, modafinil) reduce fatigue, promote alertness and wakefulness, and have possible mood-enhancing properties. In modern psychiatric practice, their use has been limited to attention-deficit hyperactivity disorder and sleep disorders such as narcolepsy. Despite this, research has continued into psychostimulant use in general psychiatry, especially in the treatment of depression and fatigue. This article reviews the recent literature regarding psychostimulant use in general and consultation-liaison psychiatry. Although psychostimulants continue to attract clinical research, there is currently not enough evidence to recommend their routine use for general psychiatric conditions.

Depression and Lability: The Effects on Occupation following Stroke

Case study methodology was used to explore the effect of emotional changes following a stroke on engagement in occupation. Two people who had had a stroke, and their partners, were interviewed. The participants' medical case notes from acute, rehabilitation and outpatient treatment were also reviewed. As a result of the stroke, one participant experienced depression and the other lability.

The case studies illustrate the impact that emotional changes can have on the performance of occupations. They also illustrate the reverse, that perceived competence in the performance of occupations can affect emotions, either negatively or positively. The results point to a need for occupational therapists to take an occupational perspective, if wellbeing is to be maximised, as they consider and address the effects of emotional changes with people who have had a stroke.

Strategy Training During Inpatient Rehabilitation May Prevent Apathy Symptoms After Acute Stroke

BACKGROUND

Apathy, or lack of motivation for goal-directed activities, contributes to reduced engagement in and benefit from rehabilitation, impeding recovery from stroke.

OBJECTIVE

To examine the effects of strategy training, a behavioral intervention used to augment usual inpatient rehabilitation, on apathy symptoms over the first 6 months after stroke.

DESIGN

Secondary analysis of randomized controlled trial.

SETTING

Acute inpatient rehabilitation.

PARTICIPANTS

Participants with acute stroke who exhibited cognitive impairments (Quick Executive Interview Scores ≥3) and were admitted for inpatient rehabilitation were randomized to receive strategy training (n = 15, 1 session per day, 5 days per week, in addition to usual inpatient rehabilitation) or reflective listening (n = 15, same dose).

METHODS

Strategy training sessions focused on participant-selected goals and participant-derived strategies to address these goals, using a global strategy training method (Goal-Plan-Do-Check). Reflective listening sessions focused on participant reflections on their rehabilitation goals and experiences, facilitated by open-ended questions and active listening skills (attending, following, and responding).

MAIN OUTCOME MEASURES

Trained raters blinded to group assignment administered the Apathy Evaluation Scale at study admission, 3 months, and 6 months. Data were analyzed with repeated-measures fixed-effects models.

RESULTS

Participants in both groups had similar subsyndromal levels of apathy symptoms at study admission (strategy training, mean = 25.79, standard deviation = 7.62; reflective listening, mean = 25.18, standard deviation = 4.40). A significant group × time interaction (F2,28 = 3.61, P = .040) indicated that changes in apathy symptom levels differed between groups over time. The magnitude of group differences in change scores was large (d = -0.99, t28 = -2.64, P = .013) at month 3 and moderate to large (d = -0.70, t28 = -1.86, P = .073) at month 6.

CONCLUSION

Strategy training shows promise as an adjunct to usual rehabilitation for maintaining low levels of poststroke apathy.

Review of Awakening Agents

Brain injuries are a serious burden of illness to Canada and the US. Advances in managing head trauma have allowed more patients to emerge from decreased levels of consciousness and helped them cope with neurocognitive, neurobehavioural, and neuropsychiatric deficits. In this article, we review the current (1986-2002) evidence surrounding the pharmacological management of arousal states and the aforementioned neurological sequelae of head injury in either acute or chronic conditions. This article will review the evidence for the use of psychostimulants (methylphenidate), antidepressants (amitriptyline, selective serotonin reuptake inhibitors, and buproprion), Parkinson’s medications (amantadine, bromocriptine, carbidopa/levodopa), anticonvulsants (valproic acid), modafinil (Provigil), lactate, hyperbaric oxygen chamber, electroconvulsive therapy, and transmagnetic stimulation, in patients following a head injury. The review did not include all anticonvulsants, neuroleptics, beta-blockers, benzodiazepines, azospirones or cognitive enhancers. Unfortunately, the quality of the evidence is generally poor, and sometimes conflicting, which in turn results in indecisive guidelines for treating patients. Accepting the inherent flaws in the evidence we feel that this paper may serve as a stepping-stone for future researchers to improve data gathering that targets neurocognitive, neurobehavioural and neuropsychiatric symptoms following a head injury.

Apathy following stroke

OBJECTIVE

We will review the available evidence on the frequency, clinical correlates, mechanism, and treatment of apathy following stroke.

METHODS

We have explored relevant databases (that is, PubMed, MEDLINE, and PsycINFO) using the following key words and their combinations: apathy, motivation, abulia, stroke, cerebrovascular disease, basal ganglia, prefrontal cortex, anterior cerebral infarction, and thalamus.

RESULTS

The frequency of apathy following stroke has been consistently estimated between 20% and 25%. It appears to be associated with the presence of cognitive impairment, a chronic course characterized by progressive functional decline, and with disruption of neural networks connecting the anterior cingulate gyrus, the dorsomedial frontal cortex, and the frontal pole with the ventral aspects of the caudate nucleus, the anterior and ventral globus pallidus, and the dorsomedian and intralaminar thalamic nuclei. Published treatment studies have been mostly limited to anecdotal case reports, generally using dopamine agonists or stimulant medications. Cholinesterase inhibitors and nefiracetam may significantly reduce apathetic symptoms. However, their efficacy was examined in relatively small clinical trials that require replication.

CONCLUSION

Apathy is a frequent neuropsychiatric complication of stroke that, although often associated with depression and cognitive impairment, may occur independently of both. Its presence has been consistently associated with greater functional decline. However, there is no conclusive evidence about which is the best treatment for this condition.

Long-term neuropsychological performance in a cohort of children and adolescents after severe paediatric traumatic brain injury

OBJECTIVE

The purpose of the present study was to evaluate progress in neuropsychological performance in children and adolescents with severe paediatric traumatic brain injury (TBI), from admission to the rehabilitation centre up to 3-12 years after the trauma.

METHODS

Children and adolescents (n = 31, mean age at injury 11.8 years, SD = 3.8; at follow-up 18.8 years; SD = 4.5) who all had suffered a TBI participated. A comprehensive neuropsychological test battery was administered at the start of rehabilitation (T1), around discharge (T2) and in the long-term (at least 3 years after rehabilitation; T3). T1 and T2 were clinical assessments; T3 was executed as a follow-up measurement for this study.

RESULTS

At T1 and T2, most problems were in the domains of attention, memory and executive functioning. At the start of rehabilitation most deficits were with performal intelligence (61%); at discharge (mean length of stay 411 days) considerably less children had severe deficits on the intelligence domain (23%). At long-term follow-up, most problems were in the domains attention, mental speed and memory. From admission to discharge 42% of the children improved on two or more cognitive tests; from discharge to follow-up this percentage was 13%.

CONCLUSIONS

In this unique study a clinical cohort of children with severe TBI was followed for many years after injury. Most cognitive deficits were found in the early phase of rehabilitation. Most children did improve on cognitive functioning (40%) during the first year after their injury, whereas at follow-up most children had not changed. At follow-up, more than half of the children (54%) attended a regular school or had a regular job, corresponding to their age and pre-morbid functioning.

Modafinil for the treatment of diminished responsiveness in a patient recovering from brain surgery

PRIMARY OBJECTIVE

This case report reviews the history and post-operative status of a 77-year-old woman who underwent transcallosal resection of an intra-ventricular haemorrhagic subependymoma and who remained in a deep post-operative state of lethargy and listlessness.

MAIN OUTCOME MEASURES

Glasgow Coma Scale (GCS) and detailed clinical observations.

RESULTS

The patient (GCS=8) was initiated on methylphenidate 20 mg per day on the 6th day after surgery, but treatment was discontinued 2 days later due to elevated blood pressure and persistent tachycardia. Pemoline 37.5 mg per day was initiated, but treatment was stopped after 3 days due to lack of response. Treatment with modafinil 400 mg per day was initiated on the 11th day after surgery and the patient's consciousness level rapidly improved on the 14th day. On the 16th day after surgery, she was completely alert (GCS=15).

CONCLUSIONS

Modafinil appeared to be beneficial for improving wakefulness and responsiveness in a patient with central nervous system trauma in the post-operative state.

Definition, diagnosis, and forensic implications of postconcussional syndrome

Injuries from blows to the head often are manifested only as subjective complaints. Postconcussional syndrome thus can be feigned for financial or psychological gain. The authors review the pathology of brain trauma, symptoms of postconcussional syndrome, and criteria for diagnosis. In addition to somatic deficits, psychological and cognitive problems are common. The likelihood and severity of postconcussional syndrome are greater for women. Malingering may be suspected in cases involving litigation, and tests to detect it are available. Treatment for postconcussional syndrome depends on the specific symptoms. Pharmacotherapies may be helpful, but care should be used in prescribing drugs that could produce deleterious CNS effects.

Selegiline in the management of apathy following traumatic brain injury

PRIMARY OBJECTIVE

To provide a brief review of apathy following traumatic brain injury (TBI) and describe the use of selegiline in a group of patients with this symptom.

MAIN OUTCOME

Four patients are described who showed improvement in Apathy Evaluation Scale scores and functional improvement, following the use of selegiline. In each case, selegiline was well tolerated whereas methylphenidate was not.

CONCLUSIONS

Selegiline shows potential for the management of apathy following TBI. This provides further evidence that impaired dopaminergic processes are prominent in the genesis of these symptoms. However, these findings require confirmation in controlled studies.

Comparing effects of methylphenidate, sertraline and placebo on neuropsychiatric sequelae in patients with traumatic brain injury

BACKGROUND

This study aimed to investigate the effects of methylphenidate and sertraline compared with placebo on various neuropsychiatric sequelae associated with traumatic brain injury (TBI).

METHODS

This was a 4 week, double-blind, parallel-group trial. Thirty patients with mild to moderate degrees of TBI were randomly allocated to one of three treatment groups (n = 10 in each group) with matching age, gender and education, i.e. methylphenidate (starting at 5 mg/day and increasing to 20 mg/day in a week), sertraline (starting at 25 mg/day and increasing to 100 mg/day in a week) or placebo. At the baseline and at the 4 week endpoint, the following assessments were administered: subjective (Beck Depression Inventory) and objective (Hamilton Depression Rating Scale) measures of depression; Rivermead Postconcussion Symptoms Questionnaire for postconcussional symptoms; SmithKline Beecham Quality of Life Scale for quality of life; seven performance tests (Critical Flicker Fusion, Choice Reaction Time, Continuous Tracking, Mental Arithmetic, Short-Term memory, Digit Symbol Substitution and Mini-Mental State Examination); subjective measures of sleep (Leeds Sleep Evaluation Questionnaire) and daytime sleepiness (Epworth Sleepiness Scale). All adverse events during the study period were recorded and their relationships to the drugs were assessed.

RESULTS

Neuropsychiatric sequelae seemed to take a natural recovery course in patients with traumatic brain injury. Methylphenidate had significant effects on depressive symptoms compared with the placebo, without hindering the natural recovery process of cognitive function. Although sertraline also had significant effects on depressive symptoms compared with the placebo, it did not improve many tests on cognitive performances. Daytime sleepiness was reduced by methylphenidate, while it was not by sertraline.

CONCLUSIONS

Methylphenidate and sertraline had similar effects on depressive symptoms. However, methylphenidate seemed to be more beneficial in improving cognitive function and maintaining daytime alertness. Methylphenidate also offered a better tolerability than sertraline.

[Pharmacological treatment of post-traumatic behavioural disorders]

OBJECTIVE

Literature review of the data concerning pharmacologic treatment of post-traumatic behavioural disorders. This review is limited to the treatment of agitation, excitation, mood lability, hostility and agressivity as defined by the NRS and excludes pharmacologic treatment of mental slowness, cognitive disorders and depression.

METHODS

Medline interrogation using keywords Traumatic Brain Injury, Agitation, Agressivity, Behaviour, Pharmacology, Neuroleptics, Benzodiazepines, Carbamazepine, Valproate, Buspirone, SSRI, Propanolol, Methylphenidate and review of recent contents. The data finally includes 29 original studies.

RESULTS

The overall level of evidence is quite low as the data mainly consist in open studies and case reports. These data and data from reviews or didactic articles suggest the efficiency of a variety of treatments. Mood-stabilizing antiepileptics, and specially carbamazepine constitute together with SSRI antidepressants the first choices. Some data suggest efficiency of buspirone, methylphenidate and atypic neuroleptics. Lithium requires close monitoring but is probably efficient. It is difficult to conclude concerning propanolol.

CONCLUSION

The available data is in favour of the use of CBZ and SSRI antidepressants. Further studies are required. It is necessary to establish clear evidence of the efficiency of CBZ and assess the effects of methylphenidate, which is almost not prescribed in France.

Psychiatric aspects of traumatic brain injury

TBI is a complex heterogenous disease that can produce a variety of psychiatric disturbances, ranging from subtle deficits in cognition, mood, and behavior to severe disturbances that cause impairment in social, occupational, and interpersonal functioning. With improvement and sophistication in acute trauma care, a number of individuals are able to survive the trauma but are left with several psychiatric sequelae. It is important for psychiatrists to be aware of this entity because an increasing number of psychiatrists will be involved in the care of these patients. Treatment should be interdisciplinary and multifaceted, with the psychiatrist working in collaboration with the patient, caregiver, family, other physicians, and therapists. The goal of treatment should be to stabilize symptoms; maximize potential; minimize disability; and increase productivity socially, occupationally, and interpersonally.

Methylphenidate: its pharmacology and uses

Methylphenidate is a commonly used medication in the United States. This central nervous system stimulant has a mechanism of action distinct from that of amphetamine. The Food and Drug Administration has approved methylphenidate for the treatment of attention-deficit/hyperactivity disorder and narcolepsy. Treatment with methylphenidate has been advocated in patients with traumatic brain injury and stroke, cancer patients, and those with human immunodeficiency virus infection. Placebo-controlled trials have documented its efficacy as an adjunctive agent in the treatment of depression and pain. This article reviews the current understanding of the mechanism of action and efficacy of methylphenidate in various clinical conditions.

Neuropsychiatric sequelae of traumatic brain injury

The authors review the psychiatric disturbances associated with traumatic brain injury. They highlight the close link between traumatic brain injury and psychiatry and provide an overview of the epidemiology, risk factors, classification, and mechanisms of traumatic brain injury. They describe various neuropsychiatric sequelae, and the respective treatments are outlined with emphasis on a multidisciplinary approach.

Effects of methylphenidate on attentional function after traumatic brain injury. A randomized, placebo-controlled trial

Attention deficits after traumatic brain injury (TBI) are common and disabling. Many pharmacologic agents have been used to ameliorate attention deficits, and considerable interest has focused on methylphenidate (MP) because of its documented efficacy in attention deficit disorder. However, clinical studies of MP in subjects with TBI have yielded mixed results. We examined the effects of MP on attentional function in individuals with TBI referred specifically for attentional assessment and treatment. Subjects were studied in a double-blind, placebo-controlled, repeated crossover design, using five different tasks designed to measure various facets of attentional function. MP produced a significant improvement in the speed of mental processing. Orienting to distractions, most aspects of sustained attention, and measures of motor speed were unaffected. These results suggest that MP may be a useful treatment in TBI but is primarily useful for symptoms that can be attributed to slowed mental processing.

Negative symptoms in stroke patients and length of hospital stay

The purpose of this study was to assess whether the presence and severity of psychiatric symptoms in stroke patients correlate with their length of stay (LOS) in a rehabilitation unit, with special emphasis on the role of negative symptoms (NS). Twenty-three stroke patients, consecutively recruited from the inpatient rehabilitation unit, were evaluated on admission with the Mini-Mental State Examination (MMSE), the Positive and Negative Symptom Scale (PANSS), the Hamilton Depression Rating Scale (HDRS), the Scale for Assessment of Negative Symptoms (SANS), and the Functional Independent Measure (FIM). NS scores significantly correlated with LOS, with SANS total score being the most informative, and the attentional impairment subscale the least. The group of patients with pronounced NS stayed in the hospital twice as long as patients with the score on the NS subscale of PANSS below 16. These two groups did not differ in their cognitive performance or in the positive symptom subscale of PANSS scores. Total FIM score on admission was lower and HDRS scores higher in patients with pronounced NS. However, these differences, unlike those of LOS, have not reached statistical significance. The presence and severity of NS in stroke patients are associated with a longer hospital stay. Identification and treatment of NS might lead to a faster discharge from rehabilitation unit.