Brain Trauma
Diagnosing Major Depression Following Moderate to Severe Traumatic Brain Injury – Evidence-based Recommendations for Clinicians
Ronald T Seel,1 Stephen Macciocchi,2 Jeffrey S Kreutzer,3 Darryl Kaelin4 and Douglas I Katz5
1. Director, Brain Injury Research, Shepherd Center; 2. Director, Rehabilitation Psychology and Neuropsychology, Shepherd Center; 3. Professor of Physical Medicine and Rehabilitation, and Professor of Neurosurgery and Psychiatry, Virginia Commonwealth University Medical Center; 4. Medical Director, Acquired Brain Injury Program, Shepherd Center; 5. Associate Professor of Neurology, Department of Neurology, Boston University School of Medicine and Brain Injury Program, Braintree Rehabilitation Hospital
Abstract
While major depression (MD) is the most common psychiatric disorder following traumatic brain injury (TBI), diagnosing MD can be challenging due to cognitive, emotional and somatic symptoms that overlap with TBI and other psychiatric disorders. Current evidence suggests that the Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) works well in the TBI population. The presence of ‘organic’ TBI sequelae that overlap with DSM-IV MD criteria do not appear to lead to false-positive MD diagnoses. Rumination, self-criticism and guilt may best differentiate depressed from non-depressed persons following TBI. Anxiety, aggression, sleep problems, alcohol use, lower income levels, poor social functioning and negative thinking are primary risk factors for the development of MD following TBI. Current evidence suggests that the Patient Health Questionnaire-9 is the best self-report scale option for depression screening after TBI. Apathy, anxiety, dysregulation and emotional lability require careful clinical consideration when making a differential diagnosis of MD in persons with TBI. Research indicates that asking specific questions about depressed mood, loss of interest or pleasure and psychosocial functioning yields the most accurate diagnosis. Practical recommendations are provided on how clinicians can improve MD diagnostic accuracy.
Keywords Depression, diagnosis, rehabilitation, traumatic brain injury (TBI), validity
Disclosure: Ronald T Seel and Jeffrey S Kreutzer are co-developers of the Neurobehavioral Functioning Inventory (NFI), which contains the NFI-Depression Scale reviewed in the manuscript. They receive a small royalty (<$250/year) for sales. The remaining authors have no conflicts of interest to declare. Received: 20 October 2010 Accepted: 1 December 2010 Citation: European Neurological Review, 2011;6(1):24–30 Correspondence: Ronald T Seel, Virginia C Crawford Research Institute, Shepherd Center, 2020 Peachtree Road NW, Atlanta, GA 30309-1465, US. E:
Ron_Seel@shepherd.org
Psychiatric disorders frequently occur following a traumatic brain injury (TBI) and depression is the most common.1,2
When psychiatric
diagnostic criteria are used, the prevalence of major depressive episode (MDE) in persons with moderate to severe TBI ranges from 26–36%.3–7
Association suggests that the first-year incidence of major depression (MD) following TBI may be as high as 50%.8
Despite the
high incidence of depression reported in research studies, detecting and diagnosing MD following TBI can be challenging in the neurology clinic. Patients, family members and examining clinicians often recognise the presence of typical indicators of a mood disturbance, such as feeling down or ‘blue’. Other diagnostic criteria for a MDE – such as poor concentration, trouble-making decisions, lability, sleep problems, decreased energy and activity and restlessness – may also be due to TBI sequelae, other psychiatric disorders, neuroendocrine dysfunction, pre-injury functioning or medication side-effects.9,10
Establishing a precise differential diagnosis of MD versus other disorders has two important implications for the clinician. First, it will have an obvious impact on the selection of a medication regimen. Further, the diagnosis of MD may alter the interpretation of signs and symptoms associated with TBI, since MD may cause or worsen
24 A recent study in the Journal Of the American Medical
This article highlights the most critical findings from a more extensive review on diagnosing depression following TBI and includes updates on recent findings.2
First, the current standard for diagnosing MD and research findings on how these symptoms manifest themselves following TBI will be presented. Second, evidence-based risk factors associated with MD following TBI are identified. Third, evidence-based recommendations are provided for the use of self-report depression scales. Fourth, common presentations and differential diagnostic considerations for MD and other common psychiatric conditions following TBI are highlighted. Finally, practical recommendations are provided for clinicians to improve the detection and diagnosis of MD following TBI.
Major Depression – Diagnostic Features The Diagnostic and Statistical Manual of Mental Disorders IV (DSM-IV)14 provides the current clinical and research standard for diagnosing mood disorders, including MD. A summary of the criteria is given in Table 1. A person must have at least five of nine depressive symptoms
© TOUCH BRIEFINGS 2011
problems such as cognitive impairment and somatic symptoms.4,6,11–13 These diagnostic and treatment challenges highlight the need to establish an empirical basis to guide the clinical diagnosis of depression after TBI.
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