i) Availability of expertise

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

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.