Valproate for Mood Swings and Alcohol Use Following Head Injury
Condition: Traumatic Brain Injury (TBI); Alcoholism
MeSH terms: Brain Injuries; Brain Injuries, Traumatic; Alcoholism; Wounds and Injuries
Study type: Interventional

Summary: 
      Successful treatment of traumatic brain injury (TBI)-induced mood lability may reduce or
      eliminate drinking behaviors in persons with alcohol abuse/dependence (AA/D) and affective
      lability following TBI. Observed clinically, the symptoms of poorly regulated affective
      expression of AA/D+TBI patients who reach alcohol abstinence do not appear to be those of an
      idiopathic mood or anxiety disorder. These symptoms do not present the severity or the same
      natural courses as do Major Depressive Disorder, Bipolar Illness, or Anxiety Disorder, for
      example. Instead, both symptoms and course appear more characteristic of the sustained affect
      lability often observed following TBI. This observation suggests that TBI survivors represent
      a patient group for whom treatment of neuropsychiatric symptoms following TBI may alleviate
      both TBI-related affect lability and also heavy ethanol use by treating the condition that is
      contextually related to excessive alcohol use.

      Based on this concept of consequently treating AA/D through the management of post-TBI
      affective lability, this study was conducted observing the efficacy of divalproex sodium on
      the severity of affective lability and AA/D in persons suffering from a moderate TBI.
      Divalproex sodium has been shown to ameliorate mood disorders, even in those with substance
      abuse problems. This drug has also shown positive results as an alternate medication to
      benzodiazapines in the treatment of alcohol withdrawal, significantly reducing the
      progression of withdrawal symptoms in patients.
    

Detailed description: 
      Despite the body's natural healing during the first year after a head injury, many veterans
      who have suffered even mild brain injuries find themselves easily upset or fearful as they go
      about their daily lives. While these reactions to the world around them were easily managed
      before the head injury, they now occur with little or no interruption and are exceedingly
      difficult to manage. Such reactions include a sense of always being upset or fearful that
      often makes it difficult to get along with family members, friends, coworkers, and employers.
      This may lead to broken marriages, unemployment, and even homelessness.

      Some people with head injuries try to manage their unmanageable moods by drinking alcohol
      because it can create a sense of calm. However, alcohol's actions are short in duration. Most
      find that they have to drink more and more for a similar calming effect, and they soon become
      dependent on alcohol. This makes working and being part of their families even more
      difficult.

      To treat the unmanageable mood, we tried a medicine called valproate, one that eases mood
      problems in people without head injury. We gave valproate to head injured persons with mood
      problems in a "non-blinded" study where both the doctor and the patient knew that the
      medicine was valproate and both were optimistic that it would work. In a small sample of
      eighteen people, 85% found mood relief and most of those either stopped drinking alcohol or
      drank much less than before. However, this might have been because both the doctor and
      patient were hopeful that the medication would make the patient feel better or because the
      medicine actually worked.

      The only way to know for sure if the medicine works is to perform a study in which people
      receive either valproate or a sugar pill while neither they nor their doctor know which one
      they are taking. This is called a double blind study, as proposed here, and will involve
      nearly three times as many head injured persons as the first study.

      If it is successful, the new study will show that valproate treatment helps head injured
      people manage their moods and allows them to return to families, friends, and work. It will
      also show that they drink alcohol less or not at all, improving their health even further.
      Then doctors will know that they can use this medicine for large numbers of people who suffer
      from head injury and help them to lead normal lives. If the outcome of the study shows that
      the medicine works well, doctors can then use this medicine to treat people with head injury
      immediately after the study results are published.
    

Intervention name(s): divalproex sodium; Placebo
Intervention type(s): Drug; Drug
Intervention description(s): Doses will be given in 250mg increments and titrated over the first four days of study until a starting dose of 750 mg is reached. The Study Oversight Team, who is not involved in any clinical visits, will be un-blinded to study drug assignment and will have plasma concentration results and adverse event reports available to them. If a subject has no adverse events and is not at therapeutic level as indicated by the blood levels, the Study Oversight Team may inform the research pharmacy to increase the dose by 1 tablet of 250 mg to 1000 mg per day. The Study Oversight Team may also inform the research pharmacy to reduce the daily dosage back down to 750 mg per day if plasma concentrations or adverse events become intolerable. The maximum dose for the purpose of this study will be 1250 mg daily and the minimum dose will be 750 mg daily. Subjects who cannot tolerate the minimum dose will be excluded from any further study participation.; Doses will be titrated over the first four days of study in the same manner as the active study drug. After titration, the research pharmacy may increase the dose by 1 tablet per day, in the same fashion that the active drug may be adjusted, so that the participant and clinical team remain blinded to the drug assignment. The research pharmacy may also reduce the daily dosage back down by one tablet per day for the same reason.
Other intervention name(s): sugar pill
Intervention MeSH terms: Valproic Acid
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: Quadruple (Participant, Care Provider, Investigator, Outcomes Assessor)
Primary purpose: Treatment
Keywords: Veterans; Traumatic Brain Injury(TBI); Alcoholism