May 20, 2010
Major depression is common and disabling after traumatic brain injury
A study of adults who had a traumatic brain injury showed that more than half — 53 percent — developed major depression in the year following their injury. A multidisciplinary team of UW researchers conducted the study, which is published in the May 19 Journal of the American Medical Association (JAMA) in a theme issue on mental health.
Every year some 1.7 million Americans suffer a mild to severe traumatic brain injury. Moderate to severe brain injury makes up about 25 percent of the total.
The patients in this study had been treated for their injury at Harborview Medical Center in Seattle, the Level 1 trauma center serving the Pacific Northwest. They had been hospitalized for conditions ranging from complicated mild to severe traumatic brain injury. The study team was led by Dr. Charles H. Bombardier, UW professor of rehabilitation medicine, and Dr. Jesse Fann, UW associate professor of psychiatry and behavioral sciences, and adjunct associate professor of rehabilitation medicine and epidemiology. Bombardier presented the results at a JAMA news conference in New York City on Tuesday.
“We found a very high prevalence of depression in the months after the head injury,” said Bombardier, “yet only 44 percent of the depressed patients received antidepressant medications or counseling.” This is especially surprising, he said, because patients with brain injury are seen regularly by health care providers in the months after their injury. Attention is directed to physical and cognitive impairments, he noted. Depression is sometimes overlooked.
Psychological impairments represent significant causes of disability in these patients. Major depressive disorder may be the most common and debilitating of these conditions. Fann explained that poorer cognitive functioning, more aggression and anxiety, greater functional disability, poorer recovery, higher rates of suicide attempts, and greater health care costs are more common when traumatic brain injury is followed by depression.
Patients who had major depression reported a lower quality of life, difficulty managing their daily routine, and less mobility, compared to similarly injured patients who were not depressed. The depressed patients also had a nine times higher rate of anxiety disorders, compared to the non-depressed patients.
The study findings, Fann and Bombardier said, suggest that proactive mental health care should be integrated into the treatment and rehabilitation of brain injured patients. Health care providers working with recently brain injured patients should realize that their patients are at high risk for depression, they noted. Screening patients for depression, and referring patients for appropriate treatment, may improve the patient’s quality of life and ability to function.
In many cases, the authors said in an interview, depression counseling therapy might need to be tailored to accommodate thinking difficulties that accompany some brain injuries, such as finding it hard to pay attention, losing a train of thought, poor memory or not being able to multi-task.
The researchers found that brain-injury patients with a previous history of depression or alcohol dependence were more likely to have an episode of major depression. However, 41 percent of the brain injury patients who became depressed had never had depression before. The severity of the injury did not predict who would or would not become depressed. People ages 30 to 44 and women developed depression at a higher rate than did others in the study group. People age 60 and over had the lowest rate of depression in the study.
The causes of head injury in the study group were motor vehicle accidents (47 percent), falls (33 percent), violence such as gunshot wounds (11 percent), and sports or recreational accidents or other causes (9 percent).
The study included 559 hospitalized adults with complicated mild to severe traumatic brain injury, who participated in structured telephone interviews at months one through six, eight, 10, and 12. Depression and anxiety were assessed with the Patient Health Questionnaire administered at each interview. The European Quality of Life measure was given at 12 months.
The researchers found that during the first year, 297 of 559 patients (53.1 percent) met criteria for major depressive disorder at least once. This rate is about eight times greater than would be expected in the general population.
The researchers wrote that several features of major depressive disorder after traumatic brain injury are pertinent to future detection and treatment efforts. These include the fact that about half of the patients who became depressed were identified by three months. A window of opportunity might be available for early identification and prevention or treatment. They note that the risk of major depression persists throughout the first year re-gardless of pre-injury depression history, and that risk of post-brain injury depression probably persists beyond 1 year.
The authors are currently conducting a study, called Life Improvement Following Traumatic Brain Injury to examine whether a specific type of counseling called cognitive behavioral therapy is effective in treating major depression after traumatic brain injury.
What is the take-home message for people who have had a brain injury? Fann said that if you can’t seem to get out of a sad mood, if you have trouble enjoying things, low energy, difficulty sleeping, or thoughts of dying or suicide, you shouldn’t simply attribute those difficulties to your brain injury.
“These are not part and parcel of brain injury,” he said. “It’s important not to ignore these symptoms, or to assume they will get better soon on their own. If you have had a depressive episode in the past, you might be at risk for a recurrence. Talk to your health care provider and ask about screening and treatment options for depression. Treatment can be effective in relieving your symptoms.”
In addition to Bombardier and Fann, others on the “Rates of Major Depressive Disorder and Clinical Outcomes Following Traumatic Brain Injury” research team were Nancy R. Temkin, professor of neurological surgery and biostatistics; Peter C. Essleman, professor and chair of the UW Department of Rehabilitation Medicine; Jason Barber, UW research consultant in neurological surgery; and Sureyya S. Dikmen, UW professor of rehabilitation medicine, who also holds appointments in neurological surgery and psychiatry and behavioral sciences.
The project was supported by grants from the National Center for Medical Rehabilitation Research of the National Institutes of Health.
Watch a video interview with Drs. Bombardier and Fann produced by JAMA.