TBI Research Review: Post-TBI Depression Mount Sinai Medical Center (page 1 of 3) Page 1 of 3

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Post-TBI Depression, Issue 1, April 2004

The aim of TBI Research Review is to summarize current research on traumatic brain injury (TBI), offer suggestions for future research planning and suggest application of research findings to clinical practice and policy. The focus in this first issue is on post-TBI depression.

What Do We Know about the Incidence, Prevalence, and Patterns of Depression after TBI?

• Depression is the most common Axis I disorder following TBI ^1-7.
• Prevalence rates vary widely in the literature. This variation is a product both of differing cohorts studied (inpatients, outpatients, community-based samples; groups varying in severity of injury and in time since injury), and of different diagnostic methods adopted (diagnostic interviews such as the Structured Clinical Interview for the DSM-IV, family interview, clinical impressions, self report).
• Depression is significantly more prevalent in individuals with TBI than in individuals without a disability 1 and in individuals with other disabilities ^7-11.
• Depression post TBI is often co-morbid with other Axis I disorders ^1,3-5,12-13, with anxiety disorders the most common co-morbidity.
• The course of depression follows many patterns. It may be chronic, as evidenced by elevated rates of post TBI depression documented many years after injury ^1,9, or it may resolve. Depression may emerge immediately or only several years after injury ¹³; a small subgroup of individuals do not become depressed post TBI ^5,13.
• Depression appears to be unrelated to demographic factors (e.g., gender, age, ethnic background, level of education) or to characteristics of injury (e.g., severity of TBI, time since injury).
• Pre-TBI history of depression is a risk factor for development of post-TBI depression ^5,13.

What Do We Know about the Psychosocial Correlates of Post-TBI Depression?

Considerable research has shown that post-TBI depression is associated with a variety of negative correlates — both for individuals with TBI and their caretakers. Compared to those who are not depressed, individuals with post-TBI depression experience:

• Poorer rehabilitation outcomes ^14-15
• Greater functional disability ^3,16-17
• Reduced activities of daily living ¹²
• Less social and recreational activity ¹⁸
• Less employment potential ¹⁹
• Elevated divorce rates ¹⁵
• Greater caregiver burden ^20-22
• Greater sexual dysfunction ²³
• Lower ratings of health ²⁴
• Poorer subjective well-being ^18,25
• Poorer quality of life ^18,26-28
• Increased rates of suicidal ideation ²⁹

It is not clear from these studies whether a causal relationship exists between depression and any of these other life elements and, if so, the directionality of the causality. It is clear, however, that depression implies a variety of other negative life circumstances.

What Do We Know about the Treatment of Post-TBI Depression?

Research on approaches to treating depression in individuals with TBI remains limited:

• Published studies of psychopharmacological treatments of depression are few, lack double-blind clinical trials and often produce mixed or unexpected results ^7,30.
• Although psychotherapy remains the preferred means of treatment of mood disorders in individuals with TBI ^1-2,31-33, studies evaluating specific approaches to psychotherapy in the treatment of post-TBI depression are inadequate, consisting primarily of uncontrolled case reports, case series, and single-case design studies ⁷.
• In treating depressive symptoms after TBI, the choice of psychotherapeutic method is important, as cognitive deficits often limit the individual’s ability to profit from psychodynamic approaches ³⁴. Individuals with TBI may benefit from treatments that specifically take into account cognitive distortions.
• Caution should be taken when utilizing psychopharmacologic treatments, as individuals with TBI are more likely to experience side effects from these medications ².

Implications for Future Research and for Dissemination

From available studies a relatively clear picture of post-TBI depression emerges: it is a highly prevalent and destructive disorder. However, too few studies lay an adequate groundwork for treatment and for understanding the dynamics of post-TBI depression. Future research should be shaped to rectify methodological weaknesses in available research as well as to address pressing questions, particularly focused on factors that provide insight on prevention and treatment:

Longitudinal studies of individuals with TBI are needed to:

• Track the patterns of emergence, resolution and chronicity of depression during the initial decade post injury,
• Identify triggers for depression,
• Identify coping strategies that inoculate the individual against depression, and
• Identify contextual and environmental elements that either prevent depression or facilitate its resolution.
• Standard assessment tools (e.g., Structured Clinical Interview for the DSM-IV, or SCID) must be utilized in diagnosing TBI and other Axis I disorders, to permit cross-study comparisons.
• Qualitative studies are needed to gain insights from people with TBI about factors — both personal and environmental — that they experience as being harmful or helpful with respect to their mood.
• Studies are needed:
• To determine if effective treatment of depression alters long-term psychosocial outcome for individuals with TBI, and
• To evaluate the impact of family interventions on the long-term adjustment of individuals with TBI.
• Future research focused on treatments should include:
• Randomized trials of antidepressant medications,
• Randomized trials of a variety of types of psychotherapy,
• Randomized trials of antidepressant medications and psychotherapy, in combination,
• Investigation of factors mediating treatment efficacy, and
• Evaluation of pre-TBI Axis I disorders as moderators of post-TBI treatment outcome.

From Mount Sinai Medical Center. www.mssm.edu.

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