Diagnosing Major Depression Following Moderate to Severe Traumatic Brain Injury
methodological issues that limited the evidence upon which definitive conclusions regarding diagnostic validity could be drawn.2
Current
evidence based on this review suggests that the PHQ-9 (see Table 3) is the best option for depression screening following TBI. The PHQ-9 acceptably rules out the presence of MD (e.g. minimizes false-negative screens) and performes better than all other scales at ruling in the presence of depression (e.g. minimizing false-positive screens) in TBI and primary care populations.
The BDI-II, CES-D, and NFI-D scales had an acceptable ability to rule out the presence of MD as a screening tool. Only the NFI-D and PHQ-9 demonstrated evidence of acceptably ruling out MD in persons with TBI. The HADS and SDS were both found to demonstrate high rates of false-negative screens and cannot be recommended for use at this time.
Differential Diagnosis of Major Depression in Persons with Traumatic Brain Injury Challenges with accurately diagnosing MD are not unique to the TBI population. In the general population, questions also arise regarding the most effective and efficient methods for diagnosing MD and how best to distinguish whether symptoms are related to depression versus co-occurring medical or psychiatric illnesses.22
The DSM-IV provides diagnostic considerations to differentiate MD, mood disorder due to a general medical condition, dementia, bipolar episodes, adjustment disorder with depressed mood, bereavement, and finally depressive disorder (not otherwise specified). Instructions are also provided for classifying MD as either a single episode or recurrent, determining whether the severity is mild, moderate, or severe and occurs with or without psychotic features.14
Differentiation of MD from a
mood disorder due to a general medical condition in persons with TBI should include a thorough review of:9,14
• pre-injury diagnoses and functioning; • sensorimotor disorders; • medical disorders; •
• adverse effects of medication; • sleep disorders; and • mood and anxiety.
This article supplements DSM-IV information by presenting four psychiatric conditions that are common to TBI and MD and which require careful clinical consideration when making a differential diagnosis of MD: apathy, anxiety, dysregulation, and emotional lability.
Major Depression and Apathy
Apathy is a common comorbidity for those who have sustained TBI—particularly early post-injury.52,53
It refers to ‘primary motivational
loss’ that includes lack of behavioral activity, cognitive initiative, and emotional engagement in purposeful activity. Primary apathy-related symptoms, including anhedonia and lack of energy, initiative, and social interaction, are often confused with depression.68,69,70
A key differential
diagnostic consideration is that those with post-TBI apathy do not show cardinal features of depression, such as sadness, irritability, hopelessness, and negativistic thinking. Those who are depressed tend
US NEUROLOGY Major Depression and Anxiety
Anxiety and MD share a number of overlapping symptoms including rumination, hypervigilance to problems and using avoidance as a coping
45
Table 5: Symptoms that Differentiate Core Features of Major Depression from Anxiety
Depression
Common Presentation Cognitions Awareness Coping style
Differential Features Mood
Rumination Anxiety Rumination
Overestimates problems Overestimates problems Avoidance
Avoidance
(frequency, situations) (constant, global) Activity level Physiological Attitude
Low activity Underaroused Cognitions
Sad, irritable, frustrated Worried, distressed (frequent, situational) Restless, ‘keyed up’ Hyperaroused
Loss of interest, pleasure Over-concern Focuses on loss, failures Focuses on harm, danger
Most common DSM-IV Major depressive episode Generalized anxiety diagnoses
Adjustment disorder disorder
with/or depressed mood Adjustment disorder with/or anxiety
Anxiety disorder not otherwise specified (mixed anxiety and depressive disorder)
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders IV.
Table 6: Symptoms that Differentiate Core Features of Major Depression from Dysregulation
Depression
Common Presentation Mood
Sad, irritable, frustrated
(frequency, situations) (constant, global) Cognitions
Rumination
Differential Features Activity level Attitude
Physiological Awareness Coping style
neuroendocrine dysfunction (notably testosterone deficiency); Low activity Dysregulation
Frustrated, angry, tense (frequent, global) Rumination
Impulsive
Loss of interest, pleasure Argumentative Underaroused
Fluctuating arousal
Overestimates problems Underestimates problems Avoidance, social withdrawal
Uncontrolled outbursts
Most common DSM-IV Major depressive episode Personality change diagnoses
Adjustment disorder with/ due to brain injury— or depressed mood
aggressive type Impulse control disorder not otherwise specified
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders IV.
to overestimate and ruminate about their problems; whereas persons with apathy are generally unaware of problems and unconcerned about failure. Individuals with post-TBI apathy are dependent and less likely to use approach-oriented and social support-seeking behaviors; whereas those who are depressed actively resist or withdraw and use avoidant coping strategies.68,71–73
Persons with apathy may be given a
DSM-IV diagnosis of personality change due to brain injury—apathetic type or, in combination with significant memory and other cognitive impairments, cognitive disorder not otherwise specified.
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