Brain Trauma


Table 3: Recommended Screening Scale for Major Depression—Patient Health Questionnaire-9


Patient Health Questionnaire-9


Directions: Over the last two weeks, how often have you been bothered by any of the following problems?


0 = not at all; 1 = several days; 2 = more than half the days; 3 = nearly every day 1. Little interest or pleasure in doing things 2. Feeling down, depressed or hopeless 3. Trouble falling or staying asleep 4. Feeling tired or having little energy 5. Poor appetite or overeating


6. Feeling bad about yourself—or that you


are a failure or have let yourself or your family down


7. Trouble concentrating on things, such as


reading the newspaper or watching television


8. Moving or speaking so slowly that other


people could have noticed. Or the opposite, being so fidgety or restless that you have been moving around a lot more than usual 9. Thoughts that you would be better off dead, or of hurting yourself in some way


10. If you have checked off any problems, how


difficult have these problems made it for you to do your work, take care of things at home, or get along with other people?


Note: A total score ≥10 on items one to nine indicates a positive screen for a major depressive episode.


Table 4: Symptoms that Differentiate Core Features of Major Depression from Apathy


Depression


Common Presentation Attitude


Activity level Physiological


Differential Features Mood


(frequency, situations) Awareness Cognitions


Coping style Apathy


Loss of interest, pleasure Loss of interests, goals Low energy and activity


Underaroused


Sad, irritable, frustrated (constant, global)


Lack of energy, initiative, activity Underaroused


Flat, lacks emotion (constant, global)


Overestimates problems Unaware of problems Ruminate on loss, failures


Lack concern about failure


Active avoidance, social withdrawal


Adjustment Disorder with depressed mood


Dependent, compliant


Most common DSM-IV Major depressive episode Personality change diagnoses


due to brain injury—


apathetic type Cognitive disorder not otherwise specified


DSM-IV = Diagnostic and Statistical Manual of Mental Disorders IV.


with increased activation in the ventral limbic and paralimbic structures, including the prelimbic cortex, amygdale, and medial thalamus.10,51,56 However, these patterns of anatomical dysfunction are not universally observed in persons with MD and variations between studies are likely attributable to heterogeneity in MD symptoms and the existence


44 0 1 2 3 0 1 2 3 0 1 2 3


• age; • gender; • race; •


0 1 2 3


0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3 0 1 2 3


of subtypes of depression.10,56 Drevets,57


Davidson,56 Moldover,10


For detailed reviews of this topic, see and Jorge.51


Pre-injury Psychiatric History


Pre-injury psychiatric history has not been consistently associated with MD after TBI. Three studies found a significant association between history of mood and/or anxiety disorders and the development of post-TBI MD,4,12,23


while two studies did not show a similar association.11,30 In contrast, a population-based study that assessed the presence of TBI and affective disorders found that persons without a prior psychiatric illness had almost five-times higher rates of affective disorders at seven to 12 months post-TBI. Individuals with TBE were more than twice as likely as the general population to be depressed 13–18 months post-TBI.58


Factors Not Associated with Depression A number of variables have been shown consistently to not be associated with depression following TBI. These include:6


markers of TBI severity; and


• post-injury functioning, including: acute care and acute rehabilitation length of stay; duration of coma; duration of post-traumatic amnesia; acute admission Glasgow Coma Scale scores; admission and discharge rehabilitation Disability Rating Scale scores; and admission and discharge rehabilitation Functional Independence Measure (FIM) scores.


Use of Self-report Depression Scales in Persons with Traumatic Brain Injury Early research suggested that persons with TBI underestimate cognitive, emotional, and behavioral impairment.59–62


However, scales that used


specific versus abstract item content mediated awareness of impairments and improved agreement between patients’ and family’s perceptions of functioning.63,64


Best current evidence suggests that


persons with TBI and their significant others do not have clinically meaningful differences in perceptions of depressive symptoms when specifically worded depression items are used.39,65,66


Clinicians often use self-report scales to case-find MD and quantitatively monitor changes in symptom severity. A number of scales have been used in clinical practice and research on depression after TBI. The Beck Depression Inventory—Second Edition (BDI-II), Center for Epidemiological Studies Depression (CES-D) scale, and Zung Self-assessment Depression Scale (SDS) are self-report measures used in primary care and mental health settings. The Patient Health Questionnaire-9 (PHQ-9) is a self-report measure that addresses the nine DSM-IV symptoms of MD. The Hospital Anxiety and Depression Scale (HADS), which is self-rated, and the Hamilton Depression (HAM-D) scale, which is clinician-rated, are frequently used in inpatient medical settings. The Neurobehavioral Functioning Inventory-Depression (NFI-D) scale is designed and validated for persons with TBI.67


A review of these assessment scales found that all TBI studies that evaluated the psychometric properties of depression scales had


US NEUROLOGY


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