TBI psychiatry — depression, aggression, capacity (MEQ)

(i) Formulation. Concurrent syndromes: (1) major depression due to another medical condition (TBI) — anhedonia, insomnia, passive SI months after moderate injury; depression is common and outcome-relevant after TBI.^[1] (2) Aggression/behavioural dyscontrol linked to bifrontal injury and frustration intolerance — clinical correlates include frontal pathology and mood comorbidity.^[5] (3) Features of personality change due to another medical condition (disinhibition, not himself) that may coexist with depression and must not be collapsed into "just depression" or primary personality disorder.^[6] Not established primary schizophrenia; not day-3 PTA only (now 5 months).

(ii) Management. Depression: adapted psychotherapy + SSRI. Sertraline is the most trial-visible agent (Fann treatment RCT; Jorge prevention RCT) — start 25–50 mg oral daily, titrate, monitor suicide risk, hyponatraemia, interactions; avoid bupropion if seizure concern.^[2][3] Aggression: medical/environmental review first; behavioural structure with rehab team. Prefer beta-blockers (e.g. propranolol low-and-slow with BP/HR monitoring) per expert recommendations rather than standing high-dose olanzapine for non-psychotic dyscontrol; reserve low-dose short-term atypical antipsychotic only for imminent danger; avoid chronic benzo/anticholinergic strategies.^[4][5][6]

(iii) Capacity. Decision-specific analysis of the business sale: understanding, retaining, weighing, communicating. Brief cognitive screen 28/30 does not prove executive weighing for a complex financial act; frontal disinhibition and depression both threaten valid consent. Pause major transactions, involve appropriate legal substitute pathways under local law, reassess after treatment and with neuropsychology if needed.^[6]

(iv) Disposition and risk. Active suicide risk plan; violence/impulse risk on unit and at home; substance screen; family education; stepwise rehab and community CL/neuropsychiatry follow-up; driving/work fitness deferred until team clearance; document least-restrictive legal status if needed.^[1][6]