Depression After Traumatic Brain Injury

Abstract

Major depressive disorder (MDD) is the most common psychiatric illness in patients with traumatic brain injury (TBI). An estimated 50% of people who sustain a TBI are at risk of developing MDD in the 1st year after injury. Post-TBI MDD is associated with a number of symptoms that can impede recovery from both conditions and impact overall quality of life. Our understanding of post-TBI depression is best understood from a biopsychosocial model; therefore, biological, cognitive, psychosocial, and environmental mechanisms are explored in this chapter. Nevertheless, more research is needed to understand why, how, and in which people MDD develops. There is a lack of research on treatments for post-TBI depression that currently leaves clinicians without evidence-based recommendations to guide their treatment choices. We present a number of clinical considerations and recommendations for practitioners treating adults with depression after TBI, with some discussion about the importance of assessment in this population. We also emphasize the need of adapting or tailoring evidence-based, psychosocial treatments for depression, particularly cognitive behavioral therapy (CBT), for people with the most common cognitive and physiological sequelae of TBI (e.g., impaired cognition, headaches, light sensitivity), and briefly acknowledge the potential role of pharmacotherapy in treatment.

FAQs: Common Questions and Answers

• Q1. Does the severity of TBI predict greater severity of depression?

• A1. There is no clear evidence to suggest that severity of TBI is a significant predictor of depression after injury, though this has been controversial in the literature. Although some researchers have found that people with more severe TBIs have a greater likelihood of experiencing worse depressive symptoms than people with less severe injuries [176], many researchers have found no correlation between injury severity and depressive severity post-TBI [43, 69, 177]. Some researchers have even argued the opposite: people with milder injuries may be more likely to experience greater depressive severity due to heightened awareness of their injury and limitations [47, 176]. In contrast to the controversial relationship between injury severity as a predictor of depressive severity post-TBI, research has consistently shown that history of depression prior to the injury and at the time of the injury is the strongest predictor of depression post-TBI [43].

• Q2. How soon after TBI can you diagnose MDD?

• A2. The answer to this question may depend on several factors, including, but not limited to, severity of injury, loss of consciousness, and period of post-traumatic amnesia. Natural recovery after TBI is typically classified first by a period of impaired consciousness, followed by a post-traumatic confusional state with amnesia, and then a period of post-confusional improvement of cognitive abilities [178]. Although there are no established guidelines on the timeline for diagnosing MDD after TBI, depression should not be diagnosed during an amnesic state; patients should be fully oriented at the time of assessment. Further, given the cognitive improvement that occurs during the first several months following the termination of an amnesic state, it may be prudent to allow some time for natural recovery to occur before delivering a psychiatric diagnosis. Without evidence-based guidelines, clinical judgment is needed. Factors worthy of consideration may include past history of MDD and/or other psychiatric disorders, as well as depression at the time of injury. One study showed that about half of patients who became depressed at some point over the course of 1 year after TBI were identified by 3 months post-injury, suggesting that early assessment and treatment may be warranted [43]. A second study also supported the feasibility of identifying depression in patients with mild TBI by 3 months post-injury [76]. These findings contrast with earlier research that argued that depression typically develops after significant time has elapsed since the injury and the patient has greater awareness of the chronicity and long-term implications of the injury [85]. Other researchers highlight the importance of careful selection of assessment tools within the first 3 months post-TBI, given the role that highly transient somatic and cognitive complaints may play in early assessment [77]. For this reason, structured clinical interview using DSM-IV criteria may be preferred over other symptom severity measures. Some people will experience depression immediately following an injury, though the question remains whether or not the symptoms are best conceptualized as a depressive disorder, adjustment disorder, and/or sequelae of the brain injury itself (i.e., increased emotionality, irritability, fatigue, cognitive disturbance), to which the clinician must evaluate on a case-by-case basis.

• Q3. Which depression measures are recommended for patients with TBI?

• A3. Earlier in the chapter, we reviewed select measures for assessing depression after TBI and highlighted the specific advantages for use in the TBI population. The Patient Health Questionnaire-9 (PHQ-9) is one appealing option because it is brief, consistent with the DSM-IV criteria for major depressive disorder, and widely used by providers. Research supports using a modified scoring algorithm for patients with TBI [65]. Alternatively, the Hospital Anxiety and Depression Scale (HADS) may be preferred as a brief self-report measure because it excludes somatic items that overlap with common TBI symptoms. As with the selection of all diagnostic and symptom severity measures, one must weigh the pros and cons in light of the intended purpose. See Table 7.1 for more information about eight select measures of depression.

• Q4. When should interventions for depression post-TBI begin?

• A4. The answer is closely tied to the above discussion about the timing of assessment and diagnosis. It is also likely to depend on the clinician’s conceptualization of depressive symptoms and the patient’s level of awareness and motivation. Some have argued that people in the acute stage of injury (less than 6 months post-injury) have limited insight into their conditions and would be unlikely to benefit from insight-oriented treatments (e.g., cognitive therapy) [85]. However, there is a strong counterargument for considering CBT, as one of the purposes of CBT is to increase awareness of maladaptive thoughts, feelings, and behaviors [179]. Patients in the early acute phase may also be well-suited for psychopharmacological interventions to address the pathophysiological and neurocognitive underpinnings of the illness [85]. When determining the appropriate timing for an intervention, it is also important to consider the individual’s risk factors (e.g., psychiatric history) and current psychosocial factors (e.g., social support, financial status, and ability to return to work), which will vary greatly among people depending upon the duration of time since injury.

• For people with TBI who do not have significant psychiatric symptoms, a CBT-informed group intervention aimed at building perceived self-efficacy may help prevent the future development of emotional distress [180, 181]. It is unknown whether or not a cognitive behavioral intervention could help prevent the development of MDD after TBI. Nevertheless, these findings highlight a potential role for early preventative intervention after TBI, especially for people with several risk factors for depression (e.g., pre-injury psychiatric history, limited social support).

• Q5. Given the range of cognitive and emotional symptoms associated with TBI, what should be addressed first in psychotherapy ?

• A5. In the absence of strong evidence to guide recommendations for post-TBI depression, this is a challenging yet important question. Each patient should be considered individually, and assessment is a key component in determining a treatment plan. As with any new patient, it is important to conduct a thorough evaluation at the start of treatment, which includes assessment of psychiatric and cognitive symptoms. In addition to measures of depression discussed earlier in the chapter, mental health providers may want to incorporate brief, self-report measures as a feasible way to assess common sequelae after TBI. Some possible measures may include Rivermead Post-Concussion Symptom Questionnaire (RPQ) , a self-report questionnaire that assesses the presence and severity of somatic, cognitive, and emotional symptoms after TBI [182]; Neuro-QoL Item Bank v2.0 Cognition Function Short Form, an 8-item, self-rated questionnaire assessing cognitive function [183]; and Neuro-QoL Item Bank v1.0 Emotional and Behavioral Dyscontrol, an 8-item self-rated questionnaire assessing the patients’ experience of emotional and behavioral dyscontrol. The National Institutes of Health (NIH) provided funding for the development of Neuro-QoL, a measurement system that evaluates and monitors the physical, mental, and social consequences experienced by people with neurological conditions. Given the strong psychometric properties, growing research support, feasibility, and free and easy access, this set of measures is one of several options for gathering important data from new patients in order to help generate a treatment plan.

• It is important to collect information on TBI sequelae to assist clinicians in developing adaptations that are likely to enhance depression treatment. Treatment planning has been conceptualized as a complex process involving sequential decisions, with consideration of information related to patient characteristics (e.g., psychiatric diagnoses, symptoms, problem areas), treatment context, presence or absence of social support, and treatment strategies [184]. Many clinicians address a patient’s central problem first and then move on to treat other problems in a sequential manner [185], while others attempt to treat comorbid conditions simultaneously. Other research has supported integrated treatment approaches, as with people suffering from severe mental illness and substance use disorders [186]. It is important to prioritize treating behaviors that may hinder a patient’s ability to fully engage with treatment, conceptualized in dialectal behavior therapy (DBT) as therapy-interfering behaviors [187]. More recent research has taken a transdiagnostic approach to treating psychopathology, meaning that it can be applied to a range of different disorders and problems [188], though this approach has not been studied in people with TBI.

• Thus far, there is no clear evidence to suggest that an individual’s degree of cognitive impairment will hinder their ability to benefit from psychological treatment. However, it is important to review neuropsychological test results when available and determine what treatment adaptations may be needed to compensate for cognitive impairment . In some cases, it can be helpful to initiate cognitive rehabilitation prior to beginning a psychosocial intervention, such as CBT. Many of the skills taught in cognitive rehabilitation, including strategies for improving executive function, organization, and memory, can enhance one’s ability to complete homework and achieve maximal benefit from CBT. Tiersky et al. [140] demonstrated that CBT and cognitive remediation are effective in reducing psychological distress and improving cognitive functioning among people with mild to moderate TBI. Prospective research is needed to confirm the efficacy of sequential delivery of CBT and cognitive rehabilitation training for people with TBI and depression.

• Q6. Are suicidal thoughts and behaviors common after TBI?

• A6. People with TBI demonstrate elevated risk for suicidal ideation, suicidal behavior, and completed suicide compared to the general population [189]. People who have sustained a TBI are 1.55–3 times more likely to commit suicide than people without TBI in the general population [145, 190, 191]. After TBI, rates of suicidal ideation and suicide attempts have been estimated to range from 7% to 28% [44, 52] and 0.8% to 1.7% [44], respectively. Few studies have utilized longitudinal designs and examined predictors of suicidal behavior following TBI. Preliminary findings have demonstrated that severity of depression after injury, history of prior suicide attempt, history of bipolar disorder, and having less than a high school education predict suicidal ideation 1 year post-TBI [192]. Similar to the general population, post-injury psychiatric disturbance is strongly associated with post-injury suicidality [193]. Lastly, premorbid history of aggression/hostility in psychiatric patients may be a risk factor for post-injury suicidality in people with mild TBI [194]. Overall, severity of injury is not significantly related to the presence of suicidal behavior (i.e., suicidal thoughts, suicide attempts) post-injury [52, 192, 193].

  In people with TBI, suicidal behavior may be a symptom of depression, or it may be related to pre-injury factors (i.e., psychiatric history, demographics) or other mood states (i.e., anxiety, impulsivity). In one study, about half of patients with TBI who reported suicidal ideation during the 1st year after injury also reported probable depression at the time of their first assessment [192]. In another study, 26.1% of participants who endorsed current suicidal ideation also met criteria for MDD [52]. In our research, we found that the majority of people with suicidal ideation 1 year post-TBI were likely to meet criteria for MDD; almost a tenth of them reported a suicide attempt in the 1st year after TBI [44]. Our findings suggested that suicidal ideation in this population may be largely conceptualized as a symptom of depression rather than a distinct neuropsychiatric sequela of TBI. In addition, nearly two thirds of people who reported at least one suicide attempt in the 1st year after TBI were likely to meet criteria for MDD at year one. Although the prevalence of depression among suicide attempters 1 year after TBI was high, it was comparatively lower than the rate of depression among suicide ideators 1 year after TBI. This suggests that other factors (i.e., impulsivity, low frustration tolerance) may play an important role in predicting who attempts suicide in the 1st year after TBI [44]. Further research is needed to understand factors related to suicidality among people with TBI [91].