Diagnosing Major Depression Following Moderate to Severe Traumatic Brain Injury


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


• age; • gender; • race; • •


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?


markers of TBI severity; and


post-injury functioning: 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 behavioural impairment.59–62


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


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/patient-rated, and the Hamilton Depression (HAM-D) scale, which is clinician-rated, are frequently used in inpatient medical settings. The Neurobehavioural 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 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. minimises false-negative screens) and performes better than all other scales at ruling in the presence of depression (e.g. minimising 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 found to provide high false-negative screen rates and cannot be recommended for use at this time.


EUROPEAN NEUROLOGICAL REVIEW 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


Apathy


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


Underaroused Sad, irritable, frustrated


(frequency, situations) (constant, global) Awareness Cognitions


Coping style


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.


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


27 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 0 1 2 3


0 1 2 3 0 1 2 3


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