Depression and Traumatic Brain Injury

In recent years, the number of traumatic brain injuries (TBI) has increased dramatically, and with it, an increase in psychiatric complications and diagnoses. To date, TBI causes more deaths and disabilities worldwide than any other incident. In the United States, emergency departments are seeing an increase in severe head injuries, accounting for a significant number of hospitalizations and long-term care. The Centers for Disease Control (CDC) warns that this “invisible epidemic” is a serious public threat because of its significant impact on quality of life.

TBI has received extra attention in the past decade because of its prevalence in the Iraq and Afghanistan Wars. In fact, many physicians and psychological researchers refer to TBI as the “signature injury” of these conflicts, leading to increases in cases of posttraumatic stress disorder (PTSD), brain damage, and death. However, the majority of incidents involve automobile-, construction-, and sports-related injuries. Violence from domestic abuse and firearms also account for many cases of TBI, including shaken-baby syndrome.

Death Rate is 20 - 50%

While the U.S. mortality rate associated with TBI is nearly 20% post-injury among the general population—and 30 to 50% among Iraq War soldiers—many incidents of severe head trauma result in mild to moderate levels of TBI. Severity and location of brain injury dictate symptoms, which are akin to the signs of concussion:

• Dizziness
• Headache
• Nausea
• Poor control of motor functioning
• Sensory problems (blurred vision in eyes, ringing in ears, funny taste in mouth)
• Sleep issues
• Fatigue

TBI's Long Term Damage

Cases that are more severe will continue long-term and typically interfere with overall cognitive functioning. Chronic issues related to TBI may cause a person to develop emotional problems, such as PTSD, and anxiety and depressive disorders. For people with a history of psychiatric disorders, the occurrence of head trauma can increase the possibilities of enduring psychiatric issues post-TBI. Failure to find employment, chronic pain, and an overall low quality of life may also increase the presence of psychiatric symptoms, post-TBI, according to a study published in the Journal of Neurotrauma. Incidents that are severe enough to cause severe shock to the head may also lead to the loss of a limb, which quadruples the chances of developing depression.

Proper Diagnoses Are Elusive

Diagnosing and treating TBI is not as simple as performing an MRI or CAT scan, and then offering a patient therapy. Many cases of TBI are underreported and remain undiagnosed, mostly because of the experienced difficulties on behalf of the patient. When compounded with the presence of a depressive disorder, a person may never seek the help he or she needs to recuperate. Depression can diminish a person’s cooperation and subjectivity; feelings of hopelessness, apathy, and despair may add complexities to the recovery process.

Researchers from the Kessler Foundation have discovered that the presence of depression and increased self-awareness (being able to distinguish one's own capabilities and restrictions) may prevent patients with TBI to reliably and accurately report problems related to their injuries. Their findings indicate that a strong relationship exists between high levels of self-awareness and depressive symptoms. People with depression may over-analyze their behaviors and feel deflated when they cannot meet their own standards. The researchers are concerned with physicians’ interpreting survey results, because depressive symptoms and higher self-awareness may hinder honest reporting, thus leading to ineffective diagnoses and treatments. By using self-reporting assessments that measure awareness, health, depression, memory, and satisfaction with life, they examined the abilities of 30 adults with TBI for one year. 

Too Much Self-Awareness?

Upon analysis, the researchers found that higher levels of self-awareness signified lower quality of life, difficulties with memory, and enhanced abilities to manipulate. Additionally, the results indicate that the presence of depression also leads to poor quality of life and overall satisfaction. The findings of this study are significant, because higher self-awareness can skew questionnaire responses, and depression increases self-awareness. Depressive symptoms typically co-exist with TBI, especially if other symptoms go unchecked.

The researchers suggest that physicians and mental health professionals work toward identifying, diagnosing, and treating depression in patients with TBI. Its existence is a threat to the recovery process. Patients with TBI may experience symptoms that can lead to developing depression, such as physical abnormalities and disabilities; issues with speech, memory, or cognitive abilities; chronic pain or loss of a limb; mood swings and other emotional deficits; and of course, symptoms of PTSD. Many of these symptoms may also lead to difficulties with employment and educational opportunities.

It is essential to provide patients with a cohesive rehabilitative plan that addresses physical, emotional/behavioral, and cognitive issues. Although treating these symptoms may alleviate and prevent the burdens of depression, the treatment of depression should be of singular importance, as it impedes all other methods of rehabilitation.

- Melissa Lavery, M.S.

References

Cincinnati Children's Hospital Medical Center. (2013, September 30). ER visits for kids with concussions skyrocketing. ScienceDaily. Retrieved February 2, 2015 from www.sciencedaily.com/releases/2013/09/130930093848.htm

Holder, S. (2009, April 15). TBI: The Invisible War Wound. Retrieved February 2, 2015, from http://www.headbraininjuries.com/tbi-the-invisible-war-wound

Kessler Foundation. (2014, February 26). Factors affecting self-reporting among people with traumatic brain injury evaluated. ScienceDaily. Retrieved February 2, 2015 from www.sciencedaily.com/releases/2014/02/140226133004.htm

Mary Ann Liebert, Inc.. (2011, July 12). Risk factors predictive of psychiatric symptoms after traumatic brain injury. ScienceDaily. Retrieved February 2, 2015 from www.sciencedaily.com/releases/2011/07/110712094205.htm

POV. (2011, November 10). Retrieved February 2, 2015, from http://www.pbs.org/pov/wheresoldierscomefrom/traumatic-brain-injury.php

The JAMA Network Journals. (2014, May 13). Large increase seen in emergency departments visits for traumatic brain injury. ScienceDaily. Retrieved February 2, 2015 from www.sciencedaily.com/releases/2014/05/140513161726.htm

Zoroya, G. (2005, March 3). USATODAY.com - Key Iraq wound: Brain trauma. Retrieved February 2, 2015, from http://usatoday30.usatoday.com/news/nation/2005-03-03-brain-trauma-lede_x.htm