What is the management approach for a patient with neuropsychiatric manifestations, including depression, anxiety, post-traumatic stress disorder (PTSD), and cognitive impairment, following a traumatic brain injury, particularly in the context of road traffic accidents in India?

Neuropsychiatric Manifestations of Head Injury: Management Approach

Immediate Risk Stratification at Presentation

Identify high-risk patients for persistent neuropsychiatric symptoms at the initial emergency department visit using validated predictors: female gender, pre-existing psychiatric history, elevated anxiety scores, loss of consciousness, assault as mechanism of injury, alcohol intoxication, and failure to recall receiving discharge information. 1, 2

• Female gender and psychological factors including coping styles, depression, anxiety, and PTSD symptoms are the strongest predictors of persistent postconcussive symptoms at 2 weeks post-discharge 1
• At 1-week post-injury, female gender, premorbid psychiatric history, and increased anxiety predict postconcussive syndrome 1
• At 3 months, anxiety and age become the dominant predictors 1
• Elevated baseline high-sensitivity C-reactive protein (hs-CRP) associates with persistent psychological problems (OR 1.54; 95% CI 1.06-2.22) and cognitive impairment (OR 1.69; 95% CI 1.14-2.51) 1

Screening for Specific Neuropsychiatric Symptoms

Screen systematically for chronic headaches, anxiety, memory problems, difficulty concentrating, sleep difficulties, and abnormal behavior at the time of emergency assessment. 2

• 18.7% of mild TBI patients report three or more postconcussive symptoms, with fatigue (17.2%) and forgetfulness (14.6%) being most common 1
• Evaluate specifically for the triad of headache, nausea, and dizziness—patients with all three symptoms have a 50% chance of developing postconcussive syndrome at 6 months 1
• Anxiety at initial presentation is the strongest predictor of persistent postconcussive syndrome at 3 months and should never be dismissed 1, 2

Comprehensive Neuropsychiatric Assessment

Conduct a thorough developmental, psychiatric, and medication history; detailed mental status examination; complete neurologic examination; and quantify neuropsychiatric symptoms using standardized inventories such as the Neurobehavioral Rating Scale or Neuropsychiatric Inventory. 3

• Assess for depression using criteria requiring at least 5 symptoms over 2 weeks, with at least one being depressed mood or loss of interest/pleasure 4
• Evaluate neurovegetative symptoms including insomnia/hypersomnia, fatigue, appetite changes, weight changes, and psychomotor changes 4
• Screen for PTSD symptoms using validated tools like the PTSD Checklist Specific (PCLS) 1
• Quantify cognitive impairments in attention, memory, and executive functioning—the most common neurocognitive consequences at all TBI severity levels 5

Discharge Instructions and Patient Education

Provide written and verbal education about neuropsychiatric symptoms to both patient and immediate caregiver using sixth- to seventh-grade reading level materials with type font ≥12 points, as patients rarely remember verbal instructions alone. 1, 2

• Instruct patients to return immediately for repeated vomiting, worsening headache, confusion, abnormal behavior, increased sleepiness, or seizures 2
• Mandate 2-3 days off work or school for patients experiencing postconcussive symptoms, with strict avoidance of strenuous mental or physical activity until symptom-free 2
• Educate about postconcussive symptoms including somatic (headache, dizziness, nausea, fatigue, oversensitivity to noise/light), cognitive (attention/concentration problems, memory problems), and affective symptoms (irritability, anxiety, depression, emotional lability) 1
• Emphasize that most adults with postconcussive symptoms recover within 3-12 months of injury 1

Follow-Up and Specialist Referral Timing

Refer to a traumatic brain injury specialist when symptoms persist beyond 3 weeks, or earlier if planning return to sports or if patient has identified risk factors. 2

• Do not delay specialist referral beyond 3 weeks of persistent symptoms, as early intervention improves outcomes 2
• High-risk patients identified at initial presentation warrant earlier follow-up given their significantly higher rates of persistent symptoms at 3-6 months 1, 2
• Arrange follow-up within days for patients with all three symptoms of headache, nausea, and dizziness given their 50% risk of postconcussive syndrome 1

Pharmacologic Management Principles

Use cautious dosing (start low and go slow) with empiric trials, continuous reassessment using standardized scales, and monitoring for drug-drug interactions. 3

• Avoid medications with significant sedative, antidopaminergic, and anticholinergic properties 3
• Use benzodiazepines sparingly, if at all 3
• For cognitive impairments, consider psychostimulants and dopaminergically active agents (methylphenidate, dextroamphetamine, amantadine, levodopa/carbidopa, bromocriptine) which may modestly improve arousal, speed of information processing, reduce distractibility, and improve executive function 5
• For depression and cognitive complaints, consider combination of rehabilitative and pharmacologic treatments 6
• When single medication provides inadequate relief or cannot be tolerated at therapeutic doses, augment with a second low-dose agent with different mechanism of action 3

Non-Pharmacologic Interventions

Integrate psychotherapy (supportive, individual, cognitive-behavioral, group, and family) as an essential component of treatment for all neuropsychiatric problems following TBI. 3, 5

• Cognitive rehabilitation is useful for memory impairments and may benefit impaired attention, interpersonal communication skills, and executive function 5
• Cognitive rehabilitation is most effective for patients with mild to moderate cognitive impairments who are relatively functionally independent and motivated to engage in and rehearse strategies 5
• Encourage involvement with local TBI support groups 3
• For medication- and rehabilitation-refractory cognitive impairments, psychotherapy assists patients and families with adjustment to permanent disability 5

Social Support and Functional Assistance

Assess and arrange for social assistance including driving support, employment accommodations, and financial assistance during recovery, as these problems may persist for at least 6 months. 1, 2

• Health service utilization and five indicators of social disruption or function are significantly higher in the mTBI group, indicating substantial morbidity 1
• Head injuries disproportionately affect the economically deprived, younger population (ages 20-45 years) in India, carrying heavy economic burden due to lost productive days 1
• The need extends beyond medical care to social assistance with driving, employment issues, and financial support 1

Context-Specific Considerations for India

In the Indian context where 60% of head injuries result from road traffic accidents, prevention strategies and improved pre-hospital care are critical components of reducing neuropsychiatric morbidity. 1

• GVK-EMRI emergency services achieve average response times of 17 minutes in rural areas and transfer >90% of patients to hospitals within 2 hours 7
• Coordinated public campaigns have increased helmet usage from 35.5% in August 2019 to 94% in July 2021 1
• Inadequate neurosurgical capacity, minimal law enforcement, and unavailability of pre-hospital care contribute to the large TBI burden 1

Critical Pitfalls to Avoid

Do not rely on home observation protocols for patients with negative CT or low-risk features, as this is not supported by evidence. 2

• Do not dismiss anxiety symptoms—they are the strongest predictor of persistent postconcussive syndrome at 3 months 1, 2
• Avoid corticosteroids as they have failed to demonstrate beneficial effects on mortality or neurological outcomes in TBI 7
• Do not discharge patients without written instructions about postconcussive symptoms, as this critical information is omitted from most discharge instruction sheets 1
• Never use permissive hypotension in TBI patients, as even single episodes of hypotension (SBP <90 mmHg) significantly worsen neurological outcomes including neuropsychiatric sequelae 7