Critical Care and Traumatic Brain Injury

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Evolving Role of C-L Psychiatrists in Critical Care and Traumatic Brain Injury

‘We can’t necessarily get them back to who they were before the injury, but we can get them better than they are now’

The evolving role of C-L psychiatrists in helping patients recover from and manage their conditions in the aftermath of catastrophic health events, such as heart attacks and traumatic brain injury, was presented by ACLP Fellows at the American Psychiatric Association annual conference.

In an invited presidential symposium Hot Topics in C-L Psychiatry Across the Lifespan, chaired by Maryland Pao, MD, FACLP, Mark Oldham, MD, FACLP, discussed psychiatric care as a vital element of critical care; and Durga Roy, MD, FACLP, addressed conference on neuropsychiatric aspects of traumatic brain injury (TBI).

Mark Oldham, MD, FACLP
Mark Oldham, MD, FACLP

“In the past, critical care was all about saving lives, and it certainly still is,” said Dr. Oldham. “But as more people survive critical illness because of advances in science, we’re turning to the question of… how we can preserve their overall functioning and their mental health.”

Dr. Oldham described an ‘A-to-F’ bundle of psychiatric care for inclusion in critical care:

  • Advocacy: C-L psychiatrists can proactively increase awareness of the mental health needs of patients and advocate for integrating mental health care in the intensive care unit (ICU).
  • Breathing support: Before patients who are intubated can be extubated, they must pass a spontaneous breathing trial that assesses their ability to breathe with minimal or no ventilator support. Psychiatrists can facilitate breathing trials by helping patients manage the distress, anxiety, panic, or agitation that can prevent success in the trial.
  • Catatonia: Psychiatrists can share their neuropsychiatric expertise and educate other health professionals on the critical care team in what to look for.
  • Delirium: Psychiatrists can promote and engage in systematic screening for delirium in critical care patients and teach other health professionals on the critical care team how to detect and manage it.
  • Enhanced psychosocial recovery: This entails providing information, first to the patient to help the patient understand what happened (that is, a plain language summary), and second to the patient’s primary care physician to ensure that the patient receives continued support and is monitored for ICU-related sequelae.
  • Family and friends: Psychiatrists can promote visits by the patient’s loved ones, encourage visitors to bring the patient’s personal effects to the hospital to comfort the patient, and record messages on tablets that the patient can view later.

“There’s a lot of distress [among patients] in the critical care setting,” said Dr. Oldham. “Paying attention to and addressing that distress as it’s happening—recognizing it, normalizing it, treating it, and providing support for it—are essential to the way we engage with patients in this setting.”

Durga Roy, MD, FACLP
Durga Roy, MD, FACLP

An estimated 2.8 million emergency department visits, hospitalizations, and deaths in the US  follow TBI each year. A growing number of individuals endure long-term cognitive, psychiatric, and physical disability.

Media attention around sports-related concussions, combat veterans’ blast injury, and civilian physical trauma have raised many questions about diagnostic and treatment approaches to neuropsychiatric symptoms after TBI, “which remain elusive with no standardization of care,” says Dr. Roy.

“While large epidemiologic studies have uncovered factors associated with better or worse outcomes, much is still not known about the optimal pharmacologic and behavioral interventions that could substantially improve the lives of these patients.”

In her address to conference, Dr. Roy explored key unresolved dilemmas of evaluation or management of neuropsychiatric sequelae after TBI across the lifespan ranging from pediatric concussions through all severities of TBI in adulthood.

She presented differential diagnosis, workup algorithms, and recent cutting-edge research for biomarker prognostication and treatment interventions, along with strength of supporting evidence.

Symptoms from TBI, said Dr. Roy, include loss of consciousness, loss of memory, alteration in mental state, and focal neurological deficits or head imaging findings. At least 43% of individuals with TBI will have some level of negative functional or neuropsychiatric sequelae, namely:

  • Emotional dyscontrol, including rapidly shifting moods, especially when triggered by trivial stimuli such as a TV commercial.
  • Behavioral dyscontrol, including aggression, combativeness, agitation, violence, impulsiveness, or sexual inappropriateness.
  • Cognitive dyscontrol, including slower processing speed, difficulty learning, problems with executive functions, and problems starting or completing a task.

Dr. Roy stressed the importance of interviewing not only patients, but their family members or caregivers as well.

“You need to ask questions about what the person was like before the TBI— what their personality was like and how they were functioning,” she said. “Can they balance a checkbook? Can they make a grilled cheese sandwich? Are they able to work? Collateral information from family members will tell you what the patient’s baseline was and where the patient is now.”

Dr. Roy added: “It is also important to be clear with patients about what is possible in terms of their recovery.

“Many times, patients will come to us and say: ‘I’m not the same person I was before my brain injury.’ This is where we focus on re-scripting their narrative. We might have to remind them that we can’t necessarily get them back to who they were before the injury, but we can get them better than they are now.”

The 90-minute presidential symposium, organised by ACLP’s immediate past president Dr. Pao, at the invitation of APA president, Petros Levounis, MD, MA, set learning objectives for its audience including skills at the end of the symposium to:

  • Discuss the importance of integrating psychiatric care in intensive care settings.
  • Recognize common neuropsychiatric conditions within the first year after TBI and identify current treatment interventions for such conditions.

 

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