Treatment for Depression after Traumatic Brain Injury: A …

J Neurotrauma. 2009 December; 26(12): 23832402.

1Departments of Psychiatry and Behavioral Sciences, Rehabilitation Medicine, and Epidemiology, University of Washington, Seattle, Washington.

2Moss Rehabilitation Research Institute, Elkins Park, Pennsylvania.

3Model Systems Knowledge Translation Center, Center for Technology and Disability Studies, University of Washington, Seattle, Washington.

Address correspondence to: Jesse R. Fann, M.D., M.P.H., Department of Psychiatry and Behavioral Sciences, Box 356560, University of Washington, Seattle, WA 98195. E-mail:Email: fann/at/u.washington.edu

The aim of this systematic review was to critically evaluate the evidence on interventions for depression following traumatic brain injury (TBI) and provide recommendations for clinical practice and future research. We reviewed pharmacological, other biological, psychotherapeutic, and rehabilitation interventions for depression following TBI from the following data sources: PubMed, CINAHL, PsycINFO, ProQuest, Web of Science, and Google Scholar. We included studies written in English published since 1980 investigating depression and depressive symptomatology in adults with TBI; 658 articles were identified. After reviewing the abstracts, 57 articles met the inclusion criteria. In addition to studies describing interventions designed to treat depression, we included intervention studies in which depressive symptoms were reported as a secondary outcome. At the end of a full review in which two independent reviewers extracted data, 26 articles met the final criteria that included reporting data on participants with TBI, and using validated depression diagnostic or severity measures pre- and post-treatment. Three external reviewers also examined the study methods and evidence tables, adding 1 article, for a total of 27 studies. Evidence was classified based on American Academy of Neurology criteria. The largest pharmacological study enrolled 54 patients, and none of the psychotherapeutic/rehabilitation interventions prospectively targeted depression. This systematic review documents that there is a paucity of randomized controlled trials for depression following TBI. Serotonergic antidepressants and cognitive behavioral interventions appear to have the best preliminary evidence for treating depression following TBI. More research is needed to provide evidence-based treatment recommendations for depression following TBI.

Key words: depression, psychiatry, review, traumatic brain injury, treatment

Traumatic brain injury (TBI) is a major cause of disability worldwide, particularly with declining mortality rates (Thurman and Guerrero, 1999). In the U.S., an estimated 1.4 million people sustain a TBI annually, and approximately 3.17 million Americans live with TBI-related disabilities (Zaloshnja et al., 2008). Rates are similar for other industrialized nations (Bruns and Hauser, 2003). Data aggregated from Europe and the U.K. suggest that 235 per 100,000 people sustain a TBI severe enough to warrant hospitalization each year (Tagliaferri et al., 2006). The societal cost of TBI, including direct medical costs and indirect costs, has been estimated at $60 billion in the year 2000 in the U.S. alone (Finkelstein et al., 2006). These statistics do not include the toll incurred in the conflicts in Iraq and Afghanistan, which by any count is expected to comprise large numbers of persons with TBI and post-traumatic stress disorder (Hoge et al., 2008; Tanielian and Jaycox, 2008).

Long-term disability from TBI has primarily been attributed to neurobehavioral factors (Kraus and McArthur, 1999; NIH consensus development panel, 1999; Rosenthal et al., 1998b), and frequently includes difficulty remaining employed, maintaining social relationships, and fulfilling many other social roles (Hibbard et al., 1998; Kreutzer et al., 2003; Sander et al., 1996). In addition to the cognitive sequelae that contribute to these limitations, debilitating psychiatric problems such as depression, anxiety, and alcohol abuse are common among persons with TBI (Brooks et al., 1986; Deb et al., 1999; Hibbard et al., 1998; Kolakowsky-Hayner et al., 2002; Seel et al., 2003a; Seel et al., 2003b; van Zomeren and van den Burg, 1985).

Major depressive disorder (MDD) appears to be the most prevalent psychiatric disorder after TBI, with a point prevalence rate over 25% (Rutherford, 1977; Schoenhuber and Gentilini, 1988; van Zomeren and van den Burg, 1985). The reported period prevalence of MDD within the first year is 33%42% (Jorge et al., 1993b; 2004), and within the first 7 years is 61% (Hibbard et al., 1998). Data from a recent prospective study of 559 subjects hospitalized after TBI revealed a prevalence rate of 52% for probable MDD within the first year after injury (Fann et al., 2003). The increased risk of depression is not limited to those with moderate to severe TBI; it is also present among those with mild TBI (Fann et al., 2004; Hoge et al., 2008). There is also an increased risk of suicide subsequent to TBI, with one study noting that 10% reported suicidal ideation at 1 year post-TBI, and 15% attempted suicide by 5 years post-injury (Brooks et al., 1986).

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Treatment for Depression after Traumatic Brain Injury: A ...