Phineas Gage
from the collection of Jack and Beverly Wilgus
The other day, a friend of mine who is also a doctor asked me a question that caught me by surprise. When I told him about my practice working with brain-injured people and the spectrum of neurologic and psychiatric symptoms they commonly exhibit, he asked me if I ever felt guilty medicating them. There were two questions he didn’t ask, but which were lurking just beneath the surface: “Isn’t it wrong to medicate someone when they don’t want to be medicated?” and “Isn’t it wrong to use medications that mess with a person’s mind?”
It’s not the first time I’ve been confronted with these questions, of course, but I was taken aback by the fact that it was coming from a doctor. Then I thought back to my own training and how, even after completing a comprehensive residency in neurology, my exposure to the treatment of brain injury was essentially zero. How could I expect a gynecologist with just a passing exposure to neurology and psychiatry in medical school to have a grasp of the unique issues the treatment of brain injury poses? If he spent even one hour with me, I’m sure he would agree with me. I absolutely do not feel guilty about medicating people, even against their wishes if it comes down to it. Granted, the people I treat are statistical outliers, the most severe cases of brain injury, but the same logic extends to more mundane situations as well.
According to the Center for Disease Control, at least one and a half million people sustain a traumatic brain injury each year. This number is based on a review of medical records related to emergency room visits, so it is likely a lowball estimate of the true incidence of brain injury, since most people who sustain trauma to the brain fail to recognize that a brain injury has even taken place, the symptoms are so brief and the return of normal brain function is so immediate. Of those who do seek medical care, the majority – about one million people – are treated and released from the emergency room after an evaluation. Those who aren’t killed outright by the injury and who require further treatment – about a quarter of a million people each year – are admitted to a hospital where they begin the process of recovery.After a person with a brain injury has been stabilized – the bleeding stopped, the broken bones repaired, the wounds stitched close, the pressure on the brain alleviated through surgical intervention – he or she is transferred to an acute rehabilitation facility often located in or near a hospital where recovery continues. Many return home at this stage, after they have learned to swallow and walk safely again, or at least once the proper safeguards and assistive devices have been put in place. Those with more serious injuries – those with significant impairments in thinking and memory, for example, such that they exist in a state of detachment from the world around them, or those with an utter inability to control their behaviors who act in ways that put themselves at risk of further injury – require more prolonged treatment than is typically provided in an acute rehabilitation setting, where people spend on average at most a few weeks. These unfortunate cases, the most severely injured, are transferred to what is known as a post-acute rehabilitation facility, where appropriate interventions for a prolonged and usually incomplete recovery can be implemented. These are the people I treat.
Often when patients are transferred to a post-acute rehabilitation facility, they are delirious and in a state of profound amnesia. This may be several weeks or even months after the injury occurred, so severe was the blow to the head they sustained. They cannot form an orderly representation of their environment because the brain cannot hold on to any information it receives from the sense organs. As a result, the world is a confusing, likely frightening kaleidoscope of half-formed impressions. They don’t know where they are, they don’t recognize members of their family, and they can’t string two moments together to form a meaningful stream of experience. In essence, they are strangers to reality. They lack awareness of their own actions and their own limitations, screaming and striking out at others trying to help them. Left to their own devices, they would run down the hallway on wobbly legs and would injure themselves further. What to do?
Doing nothing is not an option, since this would result in harm to the individual. Physical restraints can be useful for brief periods, however, I have seen on many occasions an average-sized woman in the throes of delirium require five or six strong men to be placed into restraints. Even after being secured with restraints – a belt around the waist tied to the back of a wheelchair or soft restraints tied to the rails of a bed – there is no guarantee that the agitation will subside, in fact, a person more often than not will become more agitated when restrained, and will summon strength from their deepest inner reserves, bucking against their captivity and injuring themselves further in an attempt to break free of what they perceive to be their imprisonment. Also, consider the mental anguish they must be experiencing. If the howls they produce are any indication, they are in considerable agony. I believe that in these extreme cases, not only is medication an acceptable course of action, it is the preferred course of action, even if a person is unable to give consent. Wouldn’t it be cruel not to?
Most everyone would agree with the appropriateness of medication for people on the verge of harming themselves due to malfunction of their body’s control system, but less urgent scenarios are not as cut and dry. Are medications helpful for other neurologic or psychiatric condition that are not immediately dangerous or life threatening? Should a doctor use his or her stature to recommend a medication with the potential for causing serious side effects? Usually there is a bright line drawn between any two autonomous people. When a doctor, having recognized that there are times when medication is appropriate, steps across this boundary and medicates another person, either forcibly or through persuasion, he should proceed with great humility and always judiciously, keeping the following principles in mind.
1) Understand what you are treating before you begin to treat it. In other words, start with a thorough clinical assessment, formulate a working diagnosis and use this process to generate a list of possible remedies. It’s not always possible to know everything about a condition before prescribing medication, but it’s unforgivable to skip the basic tools of the physician’s trade: a comprehensive history and physical exam. Especially with neurologic and psychiatric conditions, the presenting symptoms may be idiosyncratic and difficult to categorize, but prescribing medications should be more than a blind dart-throwing exercise.
2) Define a target symptom before prescribing a medication and reassess at a later date to determine if the treatment has been effective. If a person is being treated for low thyroid hormone or high cholesterol, blood levels will be tested prior to the initiation of treatment and will be re-evaluated periodically to determine if the treatment has been effective. The treatment of neuro-psychiatric conditions such as depression may seem more nebulous and more difficult to quantify, but by no means are they beyond measurement, and should proceed in the same way as the treatment of low thyroid or high cholesterol. If, at follow up, there has been a good response but there is room for improvement, an escalation in dose should be considered. If there is no response to even the maximum dose of medication, the medication should be stopped. A good rule of thumb is, if neither the patient nor the doctor can tell if a medication is working, it’s probably not.
3) Beware of side effects, especially at higher doses, but even at starting doses. Before prescribing a medication, ask yourself what the worst side effects might be. Weigh this risk against the potential for benefit, including the patient as much as possible in this discussion. The odds of a life-threatening side effect for most medications are very low, but usually not zero. Prescribing medication always involves risk, which is why prescriptions are a necessary part of the process in the first place. Some side effects are more likely to occur than others, and it’s important to advise a patient to be on the look-out for them. That having been said, any medication may cause virtually any side effect, and the only way to know if a person will have a particular side effect is to try a medication and see. If a patient reports an odd symptom after starting a medication and you can’t find it reported in any of the medical literature, believe the patient and not the literature. Besides, there is an easy way to determine if the symptom is a side effect of the medication. Did the symptom start when the new medication was started? Does it stop when the medication is stopped?
4) Some medications are life-long, but many are temporary. Always consider if a medication can be stopped. Of course, many medication can’t be stopped cold turkey, and it’s important to have the appropriate safeguards put in place when they are stopped, but the only way to know when a medication is no longer necessary is to stop the medication and see what happens.
5) Not everything needs a pill. The culture of medicine in this country is one in which the provision of medication, extensive diagnostic testing or surgical intervention is expected. Many times the prudent course of action is none of the above, but rather reassurance, conversation or a “wait and see” period with a plan for follow up in a few weeks. It may feel like doing nothing to both the doctor and the patient, but in reality, a doctor is more than a provider of pills, an orderer of tests and a wielder of scalpels. A doctor is a healer, and healing comes in a variety of flavors. Even when medication is appropriate to prescribe, in depression for example, other helpful remedies such as counseling, relaxation exercises, sleep hygiene, diet modification and an exercise regimen should be considered and discussed. Studies have shown that these non-pharmacologic therapies aren’t emphasized to the degree that they should be, especially considering their effectiveness.
My experience with treating brain-injured persons has taught me that there is most certainly a role for medication in the management of neurologic and psychiatric conditions. Just as cardiac medications promote healthy hearts, neuro-psychiatric medications, when used judiciously, promote healthy brains. Few things in life are more important than having a healthy brain. Medication is neither always good nor always bad. This is true for heart medications. This is true for pain medications. This is true for skin medications. And this is true for brain medications. With all medications there is great potential for their misuse. They can be associated with harmful side effects, they can be costly and ineffective, and they can distract from more effective non-pharmacologic treatments. There’s no doubt in my mindthat medications are overprescribed, but to discount the role of medication entirely is to ignore their potential to be life-saving or life-enriching. Do I feel guilty about medicating people or recommending these medications when their benefits outweigh their risks? No, but neither am I cavalier.