Diagnosing Major Depression Following Moderate to Severe Traumatic Brain Injury
Table 1: Diagnostic and Statistical Manual of Mental Disorders IV Criteria for a Major Depressive Episode DSM-IV Criteria A–E
DSM-IV Guidelines
Criterion A Symptoms 1. Depressed mood
2. Diminished interest or pleasure 3. Weight or appetite change 4. Sleep disturbance
5. Psychomotor agitation or retardation 6. Decreased energy
7. Feelings of worthlessness 8. Diminished thinking ability
9. Recurrent thoughts of death
Criterion B Not a mixed episode
Criterion C Clinically significant distress or impairment in
social, work, or other important areas Criterion D
Not due to direct physiological effects of a substance or general medical condition
Criterion E Not bereavement
Symptoms count as major depressive episode unless ‘clearly and fully accounted for’ by physiological effects of a traumatic brain injury that begin within three months of injury
For persons with acute traumatic brain injury, symptoms begin within two months of consistent memory of loss of loved one
DSM-IV = Diagnostic and Statistical Manual of Mental Disorders IV. Significant relationship problems most common
Sad, discouraged, empty, hopeless, tearful, irritable, frustrated, angry, aggressive, somatic complaints In all activities; including social withdrawal and diminished libido
5% change in body weight or decrease or increase of appetite (decrease is more typical) Typically middle or terminal insomnia; difficulty falling asleep (hypersomnia less frequent) Observable (not subjective feelings of) restlessness; slowed speech or body movement Fatigue, loss of energy, excessive tiredness, or reduced efficiency in completing tasks Excessive guilt, unrealistic negative evaluations, or delusional self-blame
Poor attention, difficulty making decisions, or memory problems (self-reported problems exceed objective evidence of difficulties)
Recurrent thoughts of death or suicide; suicidal behavior Meets both major depressive and manic episode criteria daily for one week
(criterion A). At least one of two primary criterion A symptoms must be present: (A1) depressed mood that impacts all or almost all aspects of life or (A2) markedly diminished interest or pleasure in all or almost all activities. Depressive symptoms must be present most of the day for at least two weeks to meet criterion A. In addition to this, a person must meet four more DSM-IV MD criteria:
• a mixed episode of manic and depressive symptoms must be ruled out (criterion B);
• • •
the severity of depressive symptoms should cause impairment in at least one aspect of daily functioning (criterion C);
depressive symptoms should not exclusively be due to a general medical condition or substance use (criterion D); and
depressive symptoms should not be part of bereavement (criterion E).
Depressive symptoms experienced by persons with TBI are generally similar to depressive symptoms reported in the general population. However, research suggests that persons with TBI experience a number of somewhat unique symptoms:
• • •
depressed mood (A1) in persons with TBI may be more frequently manifested by irritability, frustration, anger and aggression than sadness, feeling blue or tearfulness;6,15,16
self-reports of somatic complaints (A1, A6) and cognitive symptoms (A8) that exceed objective findings following TBI strongly suggest depression as a contributing cause;15
poor appetite (A3) is frequently reported by persons with TBI and may be a primary discriminator between depressed and non-depressed patients;16
• rumination, self-criticism and guilt are closely related to feelings of worthlessness (A7) and appear to highly differentiate depressed from non-depressed persons with TBI.15
Lack of confidence, EUROPEAN NEUROLOGICAL REVIEW
discomfort around others and social withdrawal may be indicators of depressed mood and feelings of worthlessness;15,16
and
• depressed persons with TBI are six times more likely than non-depressed persons to threaten self-harm (A9).6
Overall,
persons with TBI have a four times higher risk of committing suicide than persons in the general population (see Teasdale,17 Simpson,18
Wasserman19 and Hawton20 incidence and assessment).
Use of DSM-IV Criteria and the Risk of False-positive Diagnoses of Major Depression Following Traumatic Brain Injury
Concern has been expressed regarding the use of DSM-IV criteria to diagnose MD in persons with TBI due to the overlap of DSM-IV symptoms with the ‘organic’ symptoms of TBI. For example, persons with TBI frequently exhibit lack of initiative, weight loss, low energy, slow movement, attention problems, and sleep difficulties, which could lead to false-positive diagnoses of MD.21
Current research
indicates there is little evidence that use of DSM-IV criteria increases the risk of false-positive MD diagnoses. Persons with TBI who are depressed appear to self-report greater levels of impairment or difficulty than can be objectively quantified, even when measures of injury severity and/or cognitive functioning do not differ between the depressed and non-depressed groups.4,6,11–13
Even when ‘autonomic’ symptoms from DSM criterion A (e.g. weight change, loss of energy) are not considered in the diagnostic process, MD is diagnosed at virtually the same rate at one, three, six and 12 months post-injury compared with using all nine DSM criteria A symptoms.4
Similarly, in a group of older hospitalized patients without TBI, prevalence rates of MD did not differ when DSM-IV MD medically-related symptoms were excluded.22
characterised by rumination, self-criticism and hopelessness, are 25 Negative thinking, for reviews on suicide
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