General Considerations:
- Ensure safety of the patient by reviewing symptoms of suicidal and/or homicidal ideation (Teasdale and Engberg 2001).
- Ensure proper sleep hygiene, regular social activity, as well as physical activity as per return to play guidelines ( McCrory, 2009)
- Provide education on mindfulness, relaxation, and online psychotherapy
- Provide education on psychiatric Illness and its prevalence with concussion
- Do not delay treatment while awaiting specialist follow-up (ONF, 2013)
- Start low, and go slow with all medication. Avoid poly-pharmacy, and multiple medication changes at one time (ONF, 2013)
- Consider using validated symptoms scales such as the Beck Depression Inventory (BDI-II), the Beck Anxiety Inventory ( BAI), PTSD checklist for DSM-V. (Beck, 1988, 1996) (Blanchard, 1996)
For treatment guidelines of psychiatric illness post sport concussion, please visit:
http://onf.org/system/attachments/222/original/ONF_mTBI_Guidelines_2nd_Edition_CLINICAL.pdf
Journal Club Review of topic – http://sportmedschool.com/oldsportmedschool/?page_id=1337
| Class | Treatment | Starting Dose | Frequency | Dose Range | Maximum Dose | *Titration Schedule*Guided by clinical presentation, safety, and side effect tolerance |
| SSRI | Setraline | 25mg | OD | 50-200mg | 200mg | Can increase by 50mg per week after one to two weeks |
| Citalopram | 10mg | OD | 20-40mg | 40mg | Can increase by 20mg per week after one to two weeks | |
| Escitalopram | 5mg | OD | 10-20mg | 20mg | Can increase by 10mg per week after one to two weeks | |
| Fluoxetine | 10mg | OD | 20-40mg | 80mg | Can increase by 10 mg per week after one to two weeks | |
| SNRI | Duloxetine | 30mg | OD | 60-120mg | 120mg | Can increase by 30 mg per week after one to two weeks |
| Venlafaxine XR | 37.5mg | OD | 75-225mg | 375mg | Can increase by 75mg per week after one to two weeks | |
| NaSSA | Mirtazapine | 7.5mg | QHS | 15-45mg | 60mg | Can increase by 7.5 mg per week after one to two weeks |
| Stimulants | Methylphenidate | 5mg | TID* | 20-50mg | 60mg | Should start with OD dosing at starting dose to recognize side effects. Can titrate up to BID and TID depending on clinical presentation, side effect tolerance, and safety. |
| Alpha adrenergic blocker | Prazosin | 1mg | QHS* | 2-16mg | 16mg | Can be titrated upward over the course of four weeks. To a maximum dose of 16mg. Can be divided into three daily doses. |
* This medication summary is non-comprehensive, and is based on clinical experience, as well as literature review. It is meant to support, not guide clinical decisions. This summary may contain errors and may not reflect manufacturers recommendations.
*This medication summary has been adapted from clinical experience, in addition to elements of the following resources:
Stahl, S. Prescriber’s Guide: Stahl’s Essential Psychopharmacology Paperback. Fifth Edition. Cambridge University Press. 2013.
Marshall, et. al. Guideline for concussion/mild traumatic Brain Injury and Persistent Symptoms. Second Edition. Ontario Neurotrauma Foundation Publication. 2013.
Chrisholm, T and Gardner, D. The Yellow Card. Psychotropic Drug Reference Card. 7th Edition. Dalhousie University Publication. 2012.
Dr. Ryan Todd (Aug 27, 2015 PRND)
References:
Beck AT, Epstein N, Brown G, Steer RA. An inventory measuring clinical anxiety: Psychometric properties. Journal of Consulting and Clinical Psychology. 1988; 56:893–897.
Beck AT, Steer RA, Brown, GK. (1996). Manual for the Beck Depression Inventory-II. San Antonio, TX: Psychological Corporation Publication.
Blanchard, E. B., Jones-Alexander, J., Buckley, T. C., & Forneris, C. A. (1996). Psychometric properties of the PTSD checklist (PCL). Behavioral Research & Therapy, 34, 669-673
Marshall, et. al. Guideline for concussion/mild traumatic Brain Injury and Persistent Symptoms. Second Edition. Ontario Neurotrauma Foundation Publication. 2013.
McCrory P, Meeuwisse W, Johnston K, et al. Consensus statement on concussion in sport, 3rd International Conference on Concussion in Sport held in Zurich, November 2008. Br J Sports Med. 2009;43(1):76–90.
Teasdale TW, Engberg AW. Suicide after traumatic brain injury: a population study. J Neuro Neurosurg Psychiatry. 2001;71:436-440.
