Depression After Traumatic Brain Injury: A Review of Evidence for Clinical Heterogeneity

Depression represents a major source of disability among individuals who have suffered a traumatic brain injury (TBI), with estimates of prevalence in this population ranging over 50%. In comparison with other sequelae of TBI, depression is often poorly conceptualized and treated among acute care and rehabilitation professionals. One reason for this is the lack of clear etiological models for the development of depression following TBI. This paper argues that post-TBI depression actually represents a heterogeneous category, with multiple etiologic pathways and clinical implications. The literature in this area is reviewed, with an emphasis on an appreciation of the diversity within this clinical population. Conclusions focus on suggestions for differential diagnosis and treatment options.     

Psychobiological Treatment Response to a Two-Week Posttraumatic Stress Disorder and Mild Traumatic Brain Injury Integrated Treatment Program: A Case Report

Posttraumatic stress disorder (PTSD) and traumatic brain injury (TBI) demonstrate high prevalence and comorbidity among post-9/11 veterans. Veterans with this comorbidity often present with multiple co-occurring healthcare needs and increased clinical complexity. The current case report describes the clinical presentation of a veteran with mild TBI and PTSD, both before, during, and after treatment within a multidisciplinary 2-week intensive outpatient program involving prolonged exposure, evidence-based PTSD treatment, and Cognitive Symptom Management and Rehabilitation Therapy, evidence-based treatment for postconcussive symptoms. Mr. A was a 25-year-old White, transgender male who presented with a complex mental health history. At intake, presenting complaints included anxiety, panic attacks, nightmares, and depression secondary to military sexual trauma, as well as reported cognitive difficulties secondary to a concussion. He met current criteria for PTSD as well as panic disorder with agoraphobia. Head injury history consisted of a motor vehicle collision with less than 30 seconds loss of consciousness, brief posttraumatic amnesia, and alterations of consciousness. Mr. A demonstrated habituation during individual exposure sessions as assessed via skin conductance during imaginal exposures and decreased subjective ratings during in vivo exposures, as well as a decrease in trauma-potentiated startle response to trauma cues. Posttreatment data indicates significant reduction in neurobehavioral, posttraumatic stress, and depression symptoms and significant improvement in subjective cognitive functioning. The current findings support the feasibility and efficacy of short-term integrated treatment for complex clinical presentations and the need for larger scale research investigating combined PTSD and TBI intervention.     

Depression After Mild Traumatic Brain Injury: A Review of Current Research

Research pertaining to the occurrence of depression and/or depression symptomatology after a Mild Traumatic Brain Injury (MTBI) was reviewed. We found that methodological differences such as the criteria used to assess MTBI and depression, time that elapsed since brain injury, and control group variations confounded comparisons across studies. Nevertheless, the studies are consistent with at least a 35% prevalence of, and left frontal damage with depression after MTBI, an overlap of symptoms of depression and Postconcussion Syndrome (PCS), and indicate that depression can continue for many years following the injury. Our conclusion is that MTBI is the triggering event for a set of pathophysiological changes and a concomitant depressive episode in a vulnerable subset of the population. Due to a paucity of research, it cannot be definitively concluded that the underlying substrates of depression seen after MTBI and clinical depression are the same. Implications for future investigations are discussed.     

Women Living with Traumatic Brain Injury

Abstract

Women living with Traumatic Brain Injury (TBI) typically experience social and emotional sequelae that can be effectively addressed in the context of a psychotherapeutic relationship. Traumatic Brain Injuries can affect the full range of human functioning, from activities of daily living to experiencing a coherent sense of self. In this article, we focus on two issues, social isolation and emotional functioning, that encompass a number of key challenges facing women with TBI and are common and fruitful foci of psychotherapy. Social isolation includes marginalization in multiple communities, the invisibility of cognitive disabilities, difficulties in interpersonal relationships, and difficulties in employment and access to transportation. Emotional functioning includes posttraumatic stress symptoms, loss of self-esteem, anxiety, depression, anger, and shame. Two exemplary cases are used to illustrate the themes and underscore the complexities and realities of adjusting to TBI. Recommendations for therapists and consumers are woven throughout the paper.     

Depression Following Traumatic Brain Injury: The Validity of the CES-D as a Brief Screening Device

The validity, reliability, and factor structure of the Center for Epidemiological Studies-Depression Scale (CES-D) was examined with 253 patients seen for neuropsychological evaluation following traumatic brain injury (TBI). All patients completed the CES-D; 31 also completed the Beck Depression Inventory (BDI) and 17 completed the Minnesota Multiphasic Personality Inventory-II (MMPI-II). The CES-D demonstrated good concurrent, construct validity, significantly correlating with the BDI (r = .673, p < .0001) and the MMPI-II (Depression Scale T score r = .536, p = .027). The CES-D also demonstrated good internal consistency (coefficient alpha = .8195) and split-half reliability (Spearman–Brown r = .8284). Principal components factor analysis with varimax rotation resulted in a four-factor solution that accounted for 56.01% of the variance. The factor structure differed from the originally reported factor structure, and indicated that somatic difficulties were strongly associated with dysphoric affect in TBI patients. The CES-D is a valid and reliable screening instrument for use with TBI patients.     

Gender Differences in Cognitive and Emotional Adjustment to Traumatic Brain Injury

This study examined gender differences in cognitive and emotional status after traumatic brain injury (TBI) among 262 men and 140 women with TBI referred for neuropsychological evaluations. In this cross-sectional study, cognition was measured in terms of both absolute level of functioning (i.e., raw/standard scores) and estimated decline from premorbid levels expressed as z-deficit scores in the following domains: intelligence [Wechsler Adult Intelligence Scale—Revised (WAIS-R)], memory and attention [Wechsler Memory Scale—Revised (WMS-R)], processing speed (Trails A), and cognitive flexibility (Trails B). Emotional functioning was measured in terms of depression (Beck Depression Inventory) and general emotional distress (Brief Symptom Inventory). Kruskal–Wallis nonparametric one-way ANOVAs indicated that women and men differed significantly on 2 of 8 raw/standard cognitive scores [men demonstrated lower WMS-R General Memory (p < .05) and Trails B scores (p < .0001) and 4 of 8 relative decline scores [women demonstrated more estimated change in VIQ (Verbal IQ) [p < .0001], FSIQ (Full Scale IQ) [p < .01], and Attention (p < .01)]; men demonstrated greater estimated z-decline scores on Trails B (p < .01)]. Women reported significantly higher levels of depression (p < .01), but men endorsed significantly greater general psychological distress (p < .05). Research and assessment recommendations are suggested.     

128例重型颅脑损伤患者的临床治疗体会

探讨重型颅脑损伤的治疗方法与经验。观察128例重型颅脑损伤患者的脑部受伤情况,合并伤以及受伤到入院期间的病情变化。临床治愈113例,其中能生活自理者87例,留有后遗症者26例,死亡15例,病死率为11.72%。重型颅脑损伤病死率高,入院后重点合理的检查,积极有效的救治以及规范的康复护理是降低病死率、提高临床治愈率的关键。     

亚低温在重型颅脑损伤患者救治中的应用与思考

重型颅脑损伤是致死、致残的主要原因之一。亚低温（MHT）的应用为重型颅脑损伤患者的救治提供了新的思路和方法,国内外多个临床试验证实了其在救治中的有效性和实用性。本文结合国内外相关诊疗指南、循证医学证据和文献,辩证探讨了MHT在重型颅脑损伤患者救治中的适应证及机制、操作方法及时间窗、并发症及临床决策问题。     

Group Intervention Studies in the Cognitive Rehabilitation of Individuals with Traumatic Brain Injury: Challenges Faced by Researchers

There are many factors to consider in designing and interpreting group studies. These include both analytic considerations, such as the selection of valid and reliable outcome measures, and subjective considerations, such as the selection of outcomes that are perceived to be important to participants and researchers. In this paper, we review key issues to consider in the design of group studies in neurorehabilitation, using problem-solving studies in traumatic brain injury as an example.     

重型颅脑损伤围术期亚低温治疗路径——循证医学指导下的治疗抉择

早期动物实验研究表明亚低温能减轻脑损伤后的继发性损害,促进神经功能恢复,然而对其临床疗效不同研究结果不完全一致。本文应用循证医学思想,检索和评价国内外文献,为重型颅脑损伤患者制定了围术期亚低温实施方案。随访结果表明,亚低温可改善患者预后。     

Traumatic Brain Injury as a Risk Factor for Alzheimer's Disease: A Review

Accumulating epidemiological evidence implicates traumatic brain injury as a pathogenic agent in the development of Alzheimer's disease (AD). Considering the increase in the prevalence of both traumatic brain injury and AD in recent times, the possibility that brain trauma may provoke the early development of AD has important implications for health service planning, preventative efforts, and medico-legal compensation settlements. This paper evaluates the plausibility of the proposed link between traumatic brain injury and AD, largely by way of exploring a theoretical perspective advanced by Satz (1993) and considering recent contributions from the epidemiological, neuropathological, and biochemical literature that are pertinent to this issue. The literature reviewed provides sufficient support and empirical vindication to give credence to the proposed association between these two neuropsychological entities at the statistical, theoretical, and biological level.     

An Intensive Outpatient Program for Veterans With Posttraumatic Stress Disorder and Traumatic Brain Injury

Post-9/11 service members may return from military service with a complicated set of symptoms and conditions, such as posttraumatic stress disorder (PTSD), depression, substance misuse, and traumatic brain injury (TBI), that interfere with reintegration and impair functioning. Although evidence-based treatments that facilitate recovery exist, their successful delivery at a sufficient dose is limited. Barriers to accessing treatment combined with challenges compiling a comprehensive treatment team further delay delivery of effective evidence-based care for PTSD, TBI, and co-occurring mental health conditions. This paper describes the development of a comprehensive, multidisciplinary, 2-week intensive day program for post-9/11 veterans with complex mental health concerns. The treatment program combines skill building groups, family education, and integrative health approaches with evidence-based individual PTSD or TBI care. Initial results from the first 132 participants were notable for a 97% completion rate, as well as statistically significant and clinically meaningful reductions in PTSD, neurobehavioral, and depression symptom severity for the 107 veterans who completed the PTSD track and the 21 who completed the TBI track. These data suggest the intensive program approach is an effective, well-tolerated model of treatment for post-9/11 veterans with PTSD and/or TBI. Future controlled studies should examine the effectiveness of this intensive model compared to standard evidence-based therapy delivery, as well as longitudinal outcomes.     

Rethinking Traumatic Brain Injury from Intimate Partner Violence: A Theoretical Model of the Cycle of Transmission

ABSTRACT

Despite growing evidence of the repeated nature of traumatic brain injury (TBI) in women experiencing intimate partner violence (IPV), there is no theoretical model depicting TBIs as a cyclical process throughout a lifetime. Situational analysis methodology was used on interviews with 10 women who self-reported passing out from being hit in the head during an episode of IPV to create a theoretical model depicting the cycle of transmission of TBI. We define the cycle of transmission of TBI as the way that women experience multiple TBIs over the course of their lifetime and how TBI can be perpetuated in a family or community. The cycle begins in childhood or adolescence, when women receive a TBI from abuse, sports, or motor vehicle accident. They enter into abusive relationships with men who are also described as living with a TBI and the women receive other TBIs during this relationship. With repeating head trauma, women described increasing TBI symptoms: problems with memory, cognition, executive functioning, depression, and concentration. If they do seek help, they must choose between healthcare and protective shelter. With either choice, the element of instability could be introduced and the cycle of transmission continues. This theoretical model shows that it is necessary to move beyond individual behaviors to think about how TBIs are transmitted through communities and how untreated symptoms can impact help-seeking behavior and perpetuate other risk factors for receiving a TBI.     

Adapting Cognitive Processing Therapy to Treat Co-Occurring Posttraumatic Stress Disorder and Mild Traumatic Brain Injury: A Case Study

This case study aims to provide evidence for the effectiveness of adapting a particular manualized cognitive behavioral therapy intervention to treat co-occurring posttraumatic stress disorder (PTSD) and mild traumatic brain injury (mTBI). This study presents the treatment of a woman who experienced co-occurring mTBI and PTSD following a motor vehicle accident, a dual diagnosis that was established through a flexible assessment approach involving interviews as well as standardized psychological, neuropsychological, and neurobehavioral testing. Treatment planning led to a-priori adaptation of Cognitive Processing Therapy (CPT) to treat both her PTSD symptoms and the sequelae associated with her mTBI. The therapist maintained fidelity to the manualized structure and content of CPT protocol, adapting portions of the treatment to add specific emphasis on issues of identity confusion and role loss in service of addressing these common functional impairments that can accompany mTBI. Discussion focuses on application of CPT for future treatment of comorbid PTSD and TBI amidst complicating factors, including role losses and medical and safety issues. This case study is especially relevant due to the prevalence of co-occurring PTSD and TBI across a variety of populations.     

Using Medical Family Therapy with Parents of an Adult Child with Traumatic Brain Injury

Abstract

Acquired traumatic brain injury (ATBI) is a public health concern causing approximately 2.5 million emergency room visits in the United States annually. Medical family therapy (MedFT) displays how biological issues impact each area of a client’s life. This paper highlights how MedFT can be utilized with parents of an adult child with ATBI; the case is presented as treatment occurred with benefits of the inclusion of MedFT. Researchers propose a call to the field of marriage and family therapy to increase access of MedFT to afford more opportunities to help families who experience medical conditions.     

Traumatic Brain Injury Outcome in Older Adults: A Critical Review of the Literature

This paper is a critical overview of the literature on older adults' outcome after traumatic brain injury (TBI). Eighteen outcome studies were reviewed. Results indicated that older patients demonstrated an increased risk for negative outcome following TBI when compared to younger patients with similar injury severity. Poorer outcome was characterized by higher mortality rates, decreased likelihood of returning to preinjury living arrangement, and declines in cognitive and affective functioning. In the studies reviewed, discharge destination, global outcome scales, and standardized neuropsychological tests were the primary measures of outcome from elderly TBI. Conceptual and methodological difficulties including variability in the definition of and inadequate measures of recovery from elderly TBI, inadequate control groups, and poor follow-up were discussed. Recommendations for future outcome research to increase uniformity in defining recovery in order to enhance comparability between studies and to tailor cognitive rehabilitation to the special needs of the older TBI patient were provided.     

A Pilot Randomized Trial of an Online Parenting Skills Program for Pediatric Traumatic Brain Injury: Improvements in Parenting and Child Behavior

This pilot study examined changes in parenting skills and child behavior following participation in an online positive parenting skills program designed for young children with traumatic brain injury (TBI). Thirty-seven families with a child between 3 and 9 years of age who sustained a moderate to severe TBI were randomly assigned to one of two interventions: online parenting skills training (n = 20) or access to Internet resources on managing brain injury (n = 17). Parent–child interaction observations and parent ratings of child behavior were collected pre- and post-treatment. Generalized estimating equations and mixed models were used to examine changes in parenting skills and child behavior problems as well as the moderating role of family income on treatment response. Participants in the parenting skills group displayed significant improvements in observed positive parenting skills relative to participants in the Internet resource group. Income moderated improvements in parent ratings of child behavior, with participants in the low-income parenting skills group and high-income Internet resource group reporting the greatest improvements in behavior. This is the first randomized controlled trial examining online parenting skills training for families of young children with TBI. Improvements in positive parenting skills and child behavior support the utility of this intervention, particularly for families from lower socioeconomic backgrounds.     

Attention After Pediatric Traumatic Brain Injury: A Multidimensional Assessment

Attentional disturbance is a common complaint after TBI in children and adolescents, however, few studies have assessed post-traumatic attentional functions. The attentional constructs proposed by Mirsky, Anthony, Duncan, Ahearn, and Kellam (1991) provided a multidimensional framework for prospective assessment of late attentional disturbance after mild-moderate (n = 34) and severe (n = 57) traumatic brain injury (TBI). Attention was evaluated from 5 to 8 years after TBI in children ages 0 to 15 years at the time of injury. Children with severe TBI performed more poorly than children with mild-moderate TBI on tests comprising the focus/execute and shift constructs. Younger children scored below older children irrespective of injury severity on the Digit Span subtest and interstimulus interval scores from an adaptive rate continuous performance test reflecting the encode and sustain constructs of Mirsky et al. (1991). Age × Severity interaction effects were found for speeded perceptual-motor tests; scores were reduced following mild-moderate and severe TBI in younger children and following severe TBI in older patients. Results are discussed in terms of the vulnerability of skills in a rapid stage of development to disruption by acquired brain injury.     

Mild Traumatic Brain Injury in Sports: Neuropsychology's Contribution to a Developing Field

Mild traumatic brain injuries are common at all levels of athletic competition. Although once considered a routine part of the game, a significant amount of attention has recently been placed on these injuries at the professional, college, and high school levels. This paper reviews the epidemiology of sports-related brain injuries, the pathophysiology of the injuries, and the role of neuropsychology in this newly emerging area. Issues related to the adequacy of neuropsychological test instruments and approaches are discussed in light of future directions for research.