Diagnosing Major Depression Following Moderate to Severe Traumatic Brain Injury
Individuals with TBI may receive a dual diagnosis of MD and a dysregulation disorder. Careful consideration of pre-injury behaviour is required to differentiate a diagnosis of personality change due to brain injury (aggressive, disinhibited or combined types) from a pre-existing personality or impulse-control disorder.
Major Depression and Lability
Lability refers to sudden and uncontrollable emotional outbursts, such as pathological laughing or crying that may or may not be consistent with the person’s overall mood.23,77
With lability, crying outbursts occur
spontaneously, are triggered internally or by minor external events and resolve quickly. With MD, tearfulness may be more prolonged and congruent with the person’s overall mood. People with post-injury pathological crying are typically given a diagnosis of personality change due to brain injury – labile type.
Recommendations to Improve Diagnosis of Major Depression after Traumatic Brain Injury Clinicians, including physicians and nurses, must frequently make determinations on the presence of MD and the need for treatment in persons with TBI. Based on this empirical review and experience, the following recommendations are provided for detecting and diagnosing MD in persons with TBI:
As often as possible, practitioners should directly ask questions of the person with TBI, with family members supplying confirmation or raising points for clarification.
Asking specific, concrete questions of TBI survivors appears to minimise the potential impact of impaired self-awareness and the validity of self-reported depression symptoms.
• Anxiety, aggression, sleep problems, unemployment, lower income levels, substance use, poor social functioning and negative thinking are primary risk factors for developing MD and should trigger practitioner questions regarding mood. Persons with TBI who do
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not meet the criteria for MD but evidence risk factors should be educated, along with a family member if available, on the signs of an emerging depressive disorder and should be clinically followed.
Periodic sadness as a response to impairments and life changes is normal. Persons who are clinically depressed experience depressive symptoms most of the day every day for at least two weeks, with the severity of symptoms impacting social and/or other everyday functioning.
Self-report depression scales are best used to ‘rule out’ the presence of depression. For persons who ‘screen positive’ for depression, a diagnostic interview for MD is essential.
Research indicates that clinicians are most likely to get the MD diagnosis correct when they ask specific questions about depressed mood, loss of interest, or pleasure and psychosocial functioning.22
While individuals with TBI and in the general population experience depression similarly, depressed mood in those with TBI is more frequently evidenced by irritability, frustration, anger, hostility and aggression than sadness and tearfulness.
Rumination, self-criticism, distress and guilt are a symptom cluster that may best differentiate depressed from non-depressed persons with TBI. Clinicians should carefully assess the presence and extent of negativistic thinking and rumination, which can both clarify the diagnosis and inform the need for referral for therapy.
Persons with TBI are at a higher risk of suicidality than the general population. A diagnostic MD interview should include questions regarding suicidal thoughts, behaviour and intent.
Psychiatric conditions commonly associated with TBI, such as apathy, anxiety, emotional lability and dysregulation, require careful clinical consideration when making a differential diagnosis of MD. It is critical for clinicians to have working knowledge of specific symptoms that either overlap or distinguish between disorders.
For cases with complicated psychiatric and behavioural symptom presentations, referral to a neuropsychologist or neuropsychiatrist who specialises in TBI may be warranted. n
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