11.8b Management challenges: Medical services

i) Availability of expertise

There are a number of medical issues that provide a challenge for management.

In the case of Sam the family used to drive about 60 minutes a time to come to an appointment. They went past four or five different mental health services to receive treatment because the mental health services in the area where they lived lacked the necessary expertise and skill to manage such a patient.

ii) Medications for off label use

Another challenge is the ability of practitioners to be aware that we can use certain medications for what we call off label use.

You may not be aware of this, but when any drug is released for use in Australia it is always released with specific indications. So, for example, the medication Sertraline is released in Australia for use with major depression, in obsessive compulsive disorder and panic disorder. If you use Sertraline for any other condition it is off label use.

Often doctors who do not deal with a lot of people with traumatic brain injury will not be aware that certain medications can be used off label for people and have a positive effect. Doctors do not have time to read all the literature and everything that is published. This will sometimes limit the kind of agents or therapeutic strategies that they might use with a patient.


iii) Fatality principle

Another challenge is the fatality principle that many medical professionals have with regard to brain injury. They often see the person with the organic impairment as being resistant to treatment, being poorly compliant, and that their response is less than optimal.

This fatality principle closes their mind to even offering treatment because they see that there are other people who will benefit more from treatment and exclude people with brain injury from services. A problem with mental health services is that sometimes they see someone with an organic impairment is not going to be helped with treatment so they do not offer treatment in the first place.



iv) Facilities

One of the challenges is when we have someone who needs treatment but we do not have the facilities or institutions to manage them.

There are no specific inpatient neuropsychiatry units available to deal with the psychiatric complications of traumatic brain injury in New South Wales. We have neither the concrete infrastructure such as the building and beds, nor the staff necessary to manage such patients.

Often we have to refer people to mental health services where the resources are limited and often the person with the traumatic brain injury and a psychiatric illness resents being referred to institutional services for mental health people because they do not view themselves as mentally ill.  They view themselves as having a traumatic brain injury and the mental health symptoms are part of that traumatic brain injury.


v) Not knowing what the problem is

Medical staff cannot treat the problem if they do not know what the problem is, that is what I referred to before in the diagnostic challenges - not having enough resources to make a diagnosis.

If you do not have enough information to make a diagnosis you do not have enough information to treat the person and the problem then becomes bigger and bigger as time progresses.

A lot of the treatments that we have are not ideal and they are going to cause problems for managing patients.


vi) Do not have the capacity to consent for treatment

Some patients do not have the capacity to consent for treatment. Some may not recognise they need to have treatment. There are legal avenues that we can use to try to improve a person's ability to have treatment and to receive the necessary treatment. But there are problems with these legal avenues.

In New South Wales the two key areas that a doctor can use to ensure that a person has treatment are:

  • the Guardianship Act and
  • the Mental Health Act.

Guardianship Act

The Guardianship Act is designed to provide a guardian who then makes the decisions about medical treatment, accommodation, and financial issues.

The Act is typically designed for people who do not have the cognitive capacity to decide for themselves. If a person is mentally ill and that prevents them from consenting, then the Guardianship Act should not be utilised. The Guardianship Act has a narrow definition and the person's impairment needs to be high.

Mental Health Act

The Mental Health Act on the other hand is administered by mental health professionals and is designed to help manage people who are mentally ill.

It has a very narrow, and rigid criteria for defining what mental illness is, and the person not only has to be mentally ill but they have to be a danger to themselves or others or to damage their reputation to be able to be detained for treatment.

If a person is mentally ill and cannot consent because of their cognitive ability alone you cannot use the Mental Health Act. One of the challenges we face is that we have patients who fall between the gap, where the Guardianship Act says we cannot make a decision because the person is mentally ill, that's why they are not making a decision, and, the mental health services say "Oh but they are cognitively impaired, that is why they are not consenting for treatment, it is not their mental illness", or their mental illness is not of a sufficient severity to be able to utilise the Mental Health Act. The legal structures we have available to ensure that people are being treated are still somewhat inadequate.

In the case of Sam legal issues really weren't implicated as far as his management was concerned. He seemed to be happy to comply with treatment and take medication, the family were also happy to ensure that Dad received some form of treatment.

Answer these questions:

What are some of the management challenges for people with TBI and mental health issues that arise from the medical services?
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What are some of the management challenges for people with TBI and mental health issues that arise from the medical services?

Available of relevant expertise
Practitioners not aware they can use certain medications for off label use.
The person is often seen as being resistant to treatment, being poorly compliant, and that their response is less than optimal.
Lack of facilities
Mental health issues is undiagnosed
Mental health services saying - Oh no that's a brain injury problem and not a mental health problem.
Inability to consent
Conflict between rehabilitation goals and mental health goals