Bromocriptine and methylphenidate may be useful for treating apathetic states. An initial effect wears away in some patients, but in others a beneficial effect is maintained despite removal of the drug. Methylphenidate, with its risk of addiction and troublesome side-effects, should only be prescribed if bromocriptine has not been successful, under consultant supervision.
Insight, compliance, competence, and detention in hospital
Lack of awareness of deficits is a common problem for the head-injured person(69) and affects compliance with the treatment. As a result, the psychiatrist may be called when the patient demands to leave hospital, even though they would be at risk returning home. If there is evidence of mental disorder then it may be possible to justify detention under the Mental Health Act 1983 (England and Wales), but not if the purpose of doing so is merely to treat a physical condition.
Insight and capacity to consent to treatment should be assessed. Only the very exceptional patient who is demanding to leave hospital following a head injury, and who as a result would be putting his or her health severely at risk, will be found to be competent. In this situation, in England and Wales, it may be possible to detain patients in hospital under common law in their best interests for treatment of a physical condition.
The patient's capacity to give informed consent to any treatment that is being offered may need to be reviewed. They should also be assessed to see whether they are capable of managing their domestic and financial affairs. If they are not, appropriate legal arrangements should be made; in the United Kingdom a receiver may need to be appointed to protect their interests. The prospect of compensation should be considered and, if appropriate, they should be enabled to pursue a personal injury claim.
Head-injury services tend to be very heterogeneous and poorly co-ordinated.(70) A head injury co-ordinator or team who identify patients at the outset, i.e. shortly after admission to hospital, is the best solution. They can identify the appropriate services for that individual and ensure continuity of service provision. It helps if there is a named local psychiatrist interested in neuropsychiatry for them to liaise with. The psychiatrist should also be part of the liaison service for the district general hospital, in particular to the trauma unit and neurosurgery. A regional neurobehavioural unit, managing challenging behaviour arising from head injury and other acquired brain injuries, should be available.
Generally brain-injury services are poorly funded. It is often difficult to find services to refer the patient to. In the United Kingdom a recent trial of case management failed to show a beneficial effect, probably because there were insufficient local resources to take on the patients' care.
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