Medication, Substances and Mental Health in ABI: Managing Risk, Consent and Safe Daily Practice

Medication and substance use are two of the most common “hidden drivers” of mental health deterioration after acquired brain injury (ABI). A change in antidepressants, missed anticonvulsants, increased alcohol intake or unrecognised side effects can quickly amplify anxiety, paranoia, aggression, low mood or suicidal ideation. This article sits within mental health and dual diagnosis in ABI and assumes delivery through ABI service models and care pathways that integrate clinical oversight, robust record-keeping and clear risk escalation.

Good practice is not simply “staff remind the person to take their meds”. It is a system: consent, safe administration where appropriate, monitoring for side effects, escalation when adherence slips, and governance oversight that turns day-to-day events into defensible evidence.

Why medicines and substances interact differently after ABI

ABI can affect memory, executive function, judgement and impulse control. People may forget doses, double-dose, self-adjust medication, or struggle to understand risk information. Alcohol and drugs can have stronger cognitive and emotional impacts post-injury, increasing falls risk, disinhibition, self-harm risk and vulnerability to exploitation.

Common medication-related risk patterns include:

• Sedation leading to reduced engagement, self-neglect or falls
• Agitation or insomnia after medication changes
• Seizure risk due to missed anticonvulsants
• Increased suicidal ideation during antidepressant titration

Operational example 1: Missed medication driving behavioural escalation

A man with ABI and epilepsy became increasingly irritable, impulsive and sleep-deprived. Staff discovered he had not been taking anticonvulsants consistently for two weeks due to forgetfulness and poor routine.

The provider introduced a structured medication routine: prompts at consistent times, visual cues in the environment, and daily recording of adherence. Staff liaised with the GP to review whether a monitored dosage system was suitable. A risk plan set clear escalation thresholds (missed doses, seizure activity, mood deterioration). Effectiveness was evidenced through stable sleep, reduced irritability and zero missed doses over the next month, recorded in daily notes and reviewed in supervision.

Operational example 2: Antidepressant change and emerging suicidality

A woman with ABI and depression had an antidepressant change. Within a week, staff noticed marked agitation and tearfulness, and she disclosed suicidal thoughts.

The provider treated this as Red-stage risk: urgent GP contact, mental health referral, safeguarding consideration and increased support presence. Day-to-day delivery included practical safety planning (removing immediate hazards proportionately), supportive listening without panic-driven interrogation, and structured routine to reduce isolation. Family contact was coordinated to avoid overwhelm. Effectiveness was evidenced through reduced suicidal ideation, improved mood stability and documented clinical review outcomes.

Operational example 3: Alcohol use increasing vulnerability and exploitation

A man with ABI began drinking heavily after a bereavement. He started inviting unknown individuals into his home and giving away money, then became paranoid and aggressive when staff raised concerns.

The provider balanced autonomy with safeguarding. Staff focused on harm reduction: agreeing safer drinking boundaries, structured activity during high-risk times, and daily financial safety checks with consent. A multi-agency approach included safeguarding consultation, GP review and liaison with substance misuse services. Capacity was assessed regarding financial decisions where concerns escalated. Effectiveness was evidenced through reduced contact with unknown visitors, improved budgeting stability and fewer aggressive incidents.

Day-to-day safe medication practice in ABI

Medication safety in ABI requires more than compliance prompts. Services should embed:

• Clear consent and role boundaries: who can prompt, who can administer, and what training is required.
• Monitoring: sleep, appetite, agitation, mood changes, falls, and cognition changes after medication adjustments.
• Accurate records: consistent daily logging of adherence and observed side effects.
• Escalation triggers: missed doses, suspected overuse, adverse reactions, or sudden deterioration.

Substance use: practical harm reduction and safeguarding

Where substance use exists, services need a pragmatic approach that reduces risk without unrealistic “zero tolerance” assumptions. Practical controls may include:

• Agreed routines to reduce isolation and high-risk times
• Support to attend appointments (GP, substance services, mental health)
• Monitoring signs of intoxication, withdrawal and vulnerability
• Clear safeguarding thresholds for exploitation, self-neglect or violence risk

Capacity, consent and best interests

Medication refusal, unsafe self-administration or high-risk substance use may raise capacity questions. Providers should avoid blanket assumptions (“he has ABI so lacks capacity”). Instead, assess decision-specific capacity where choices create significant harm risk. Where best interests decisions are required, document the process, involvement of representatives and least restrictive options considered.

Governance and assurance mechanisms

Commissioners and inspectors expect medication and substance-related risk to be governed. Strong providers evidence:

• Medication audits (errors, adherence gaps, side-effect monitoring)
• Training and competency assurance for prompts/administration
• Incident trend analysis linking deterioration to meds/substances
• Escalation logs showing timely contact with clinicians

Commissioner expectation

Commissioner expectation: commissioners will expect providers to prevent avoidable deterioration linked to medicines and substance use, reduce crisis presentations and maintain placement stability. They will look for integrated working and measurable outcomes.

Regulator expectation (CQC)

Regulator / inspector expectation (CQC): CQC will expect safe medicines practice, clear consent and role boundaries, and evidence that risks are assessed and reviewed. Inspectors will look for learning from medication incidents and safeguarding responses where vulnerability increases.

Impact and outcomes

When services manage medication and substance-related risk consistently, people experience fewer crises, better mental health stability and safer daily routines. Providers gain defensible evidence of safe practice, lawful decision-making and effective partnership working.

---