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Neurology Today:
doi: 10.1097/01.NT.0000384114.41451.91
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TBI Associated With Major Depression: Screening for Depression Urged

TALAN, JAMIE

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ARTICLE IN BRIEF

Investigators found that about half of 559 patients who had traumatic brain injury suffered from major depression for a year after the injury.

Traumatic brain injury (TBI) may lead to major depression, according to a new study conducted by scientists at the University of Washington School of Medicine in Seattle. The team followed 559 patients for a year after the injury and found that about half of them were suffering from major depression, a rate much higher than expected. The results of the study appeared in the May 18 issue of the Journal of the American Medical Association (JAMA).

Other studies have reported higher rates of depression among TBI patients but the sample sizes were small, there was selection bias, the studies were retrospective, and many relied on invalidated measures of depression and did not take into account a history of depression at the time of the injury.

In the current study, Charles H. Bombardier, PhD, Jesse R. Fann, MD, and colleagues conducted a large prospective study that recruited consecutive patients hospitalized at the Harborview Medical Center Level 1 trauma center for complicated mild to severe TBI, based on Glasgow Coma Scale ratings and observable abnormalities on brain scans.

Assessments of depression and anxiety were done monthly on 559 patients from one to six months and at eight, 10, and 12 months after the injury.

People who screened positive for major depressive disorder in the first three months and interviewed twice subsequently during the study reported that they were depressed for a median of four months. Sixteen percent of the patients had depression at the time of the injury.

The scientists found that 53 percent of the individuals met criteria for major depression at some point in the study. Half of them were depressed within the first three months, said Dr. Fann, an associate professor in the department of psychiatry and behavioral sciences and a co-author of the study. They were eight times more likely than the general population to have a major depression.

Among other findings, those with major depressive disorder were more likely to report a high level of anxiety, 60 percent versus 7 percent of TBI patients without depression. Those with depression reported a lower quality of life and more functional impairment at one year than those without a diagnosis.

“We were surprised that the rates of depression and anxiety were so high,” said Dr. Fann, who added that they were also able to tease out factors that increased a person's risk for major depression. The risk increased if patients had a prior history of depression, were depressed at the time of injury, were female, had a history of alcohol dependence, and were under 60 years old. The severity of the injury did not predict depression. Dr. Fann said that it is possible that people in the peak of their prime - from 30 to 44 years old - might notice the impact of their injuries the most and rate their functioning and health as particularly affected.

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What also became apparent as the scientists followed them over the year was that only 44 percent of those with major depression had received any treatment, either medication or psychotherapy, for their symptoms.

“Clinicians and patients need to realize that major depression is very common after traumatic brain injury and is associated with significant disability,” said Dr. Fann. The signs include depressed mood, loss of interest in activities, fatigue, decreased sleep, concentration or appetite, and thoughts of suicide. Neither doctors nor patients “should assume that these symptoms are just a normal reaction to their brain injury,” he added.

The findings suggest that routine screening for depression in the months following a TBI may be critical.

Systematic integration of mental health services into standard care of patients with TBI may be needed to improve long-term outcomes after TBI,” they wrote in the JAMA study. “Within inpatient rehabilitation, integrated clinical pathways can be used to organize early identification, risk assessment, diagnosis, and guideline-driven treatment of major depressive disorder [MDD].”

The researchers admit that the study had limitations. They relied on structured telephone interviews using a depression and anxiety measure rather than in person assessment. Also, the patient population may have been skewed since the study was conducted at a single level 1 trauma center that serves the northwestern United States and there were high rates of Medicaid recipients. Still, they added, “because MDD after TBI is an invisible disorder within an often invisible injury, aggressive efforts are needed to educate clinicians about the importance of MDD in this population.”

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EXPERTS COMMENT

“We've also found high rates of depression among patients with traumatic brain injury,” said Robert Robinson, MD, Penningroth Professor and Head of Psychiatry at Carver College of Medicine of the University of Iowa, who has also studied the link between depression and stroke. The connection is part of the diagnostic inquiry

“If someone has depression after TBI their recovery is compromised,” said Dr. Robinson. “The amount of impairment is greater and they are less likely to return to work.” No one knows whether TBI outcomes will change with treatment of depression or even trying to prevent it on the heels of a traumatic brain injury, he added. “We just don't have enough data to know,” said Dr. Robinson. “We are doing those studies now.”

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Figure. DR. JEFFREY ...
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“Depression is extremely common but much more so in people with diseases that affect the nervous system,” said Jeffrey M. Lyness, MD, director of geriatric psychiatry at the University of Rochester. “Their finding is not surprising.”

Dr. Lyness agreed that it is tough to know whether depression is a consequence of having a serious physical illness or a physiological manifestation of the illness. “It can be both,” he said. “Given the high incidence of depression in TBI patients it makes sense to conduct studies to see whether treatment works to prevent depression,” he added. “Such studies clearly need to be done.”

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References

Bombardier CH, Fann JR, Dikmen SS, et al. Rates of major depressive disorder and clinical outcomes following traumatic brain injury. JAMA 2010;303(19):1938–1945.

©2010 American Academy of Neurology

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