Derryck H. Smith, MD, FRCPC

Mild traumatic brain and psychiatric illness

Psychiatric illness, particularly depression, is common after brain , but there are a number of treatments we can use to help these patients.

ABSTRACT: Psychiatric illness, 1 ishman was one of the first vated. particularly depression, has an in- 3 authors to note the association Jorge and colleagues noted major creased incidence following mild L between depression in 33% of 91 patients who traumatic brain injury, possibly as a andthe development of psychiatric dis- had sustained a traumatic brain injury. result of damage to the frontal lobes. orders. It is not surprising that there They also noted comorbid in This damage may also lead to per- would be an increased risk of these 76.7% and aggressive behavior in sonality change and attentional types of diagnoses following a trau- 56.7%. Forty of their patients hadsus- problems. A number of treatment matic brain injury, since the parts of tained a mild traumatic brain injury options, including psychotherapy the brain most susceptible to damage (mTBI), with the rest having moderate and the use of medications, should from trauma are the frontal and the and severe injuries. Mah and col- be considered. 4 parietal lobes, which are also known leagues found deficits in social per- to be the location of most psychiatric ception after damage to the orbital disorders. frontal cortex. These changes inter- It is generally accepted that the fered with the patients’ ability to ac- incidence of psychiatric illness and curately evaluate emotional facial other neurobehavioral difficulties in- expressions. 5 creases with the severity of traumatic Recently, Levin and colleagues brain injury. The primary care physi- studied a cohort of 125 adults with cian should be alert to the possibility mild traumatic brain injury. Review- of psychiatric illness in brain-injured ing their own earlier work, they cited patients and be prepared to assess, an incidence of major depression of treat, and refer as necessary. 17% in individuals with mildtraumat- Depression ic brain injury 1 year postinjury. In their more recent work, they noted an Depression is by far the most com- Dr Smith is head of the Department of Psy- mon psychiatric sequela following chiatry at Children’s and Women’s Health traumatic brain injury, with Centre in Vancouver, BC, and a clinical pro- reported prevalence “ranging over 2 fessor in the Department of Psychiatry at 50%.” Furthermore, patients are at the University of British Columbia. He also risk for developing depression not only serves on the Review Panel of the Ontario in the acute phase but for decades after Neurotrauma Foundation. the injury, when their risk remains ele-

510 BC MEDICAL JOURNAL VOL. 48 NO. 10, DECEMBER 2006 Mild traumatic brain injury and psychiatric illness

increasing incidence of depression based on age, and that incidence in- Since individuals with mTBI have creased by a factor of 7, depending on whether there were abnormal CT find- relatively shortened periods of ings on brain imaging. associated with the trauma, PTSD is The differential diagnosis of de- pressive symptomatology following a more common in individuals with mTBI brain injury includes the following: than with severe brain injury. • Adjustment disorder with depressed mood • andemotional lability dueto frontal lobe syndrome DSM-IV-TR • Dysthymia psychiatric review. A more detailed cribedin (generalizedanx- • Major depression review by the same authors is avail- iety disorder, disorder, If it is determined that the depres- able as part of the British National posttraumatic stress disorder, obses- secondary sion or mood disorder is to Guidelines project. A number of repro- sive-compulsive disorder, and panic brain injury, it should be recorded ducible practical tools, including disorder) all have increased rates fol- DSM-IV-TR using as “a mood disorder information sheets for patients, are lowing brain trauma. The disorder may due to a general medical condition included. The flow chart in the accom- be due directly to the brain injury Figure (brain injury).” panying is one of these tools. itself, or be secondary to the life expe- Screening for depressive illness Bipolar disorder riences that are associated with the can be done using clinical interview or trauma. In some cases the disorder can any standard checklists such as the It is accepted that bipolar disorder after be specific to a lesion in the brain. Hamilton or Beck Depression Inven- brain injury is extremely rare. Sayal This is particularly the case with 7 tory. andcolleagues describe a case of bipo- obsessive-compulsive disorder, which The treatment of depressive illness lar injury following mTBI with small is associated with certain subcortical following mTBI is generally the same lesions in the right amygdala, right lesions. as for mood disorders not related to putamen, and right of the pituitary Posttraumatic stress disorder trauma. Because injured individuals gland. (PTSD) involves the re-experiencing may be suffering pain as well as a psy- Treatment of all of these disorders of associated with the trau- chiatric disorder, particular borrows on treatment protocols devel- ma. Therefore, individuals who suffer needs to be paid to treating problems oped for individuals who are not brain a dense amnesia at the time of the trau- with sleep secondary to pain as part of injured. There are, however, no con- ma have some, but not absolute, pro- the overall approach to mood distur- trolled trials of either psychotherapy tection against developing PTSD. bance and psychiatric disorders in gen- or medications specific to the brain- Since individuals with mTBI have rel- eral. damaged population. atively shortened periods of amnesia 2 Moldover and colleagues have Psychoeducational approaches and associated with the trauma, PTSD is recently argued that depression repre- supportive psychotherapy will benefit more common in individuals with sents a heterogeneous category with patients in the acute stages of recovery mTBI than with severe brain injury. 8 multiple etiological pathways. They from their injuries. Cognitive-behav- Hiott and Labbate have reviewed present suggestions on differential ioral therapy is probably the treatment anxiety disorders following traumatic diagnosis and treatment options. of choice, although it must be remem- brain injury. They report a number of One of the most practical recent bered that may have been studies with high incidence of PTSD, publications is by Turner-Stokes and adversely affected by the brain injury but note that the re-experiencing crite- 6 MacWalter, who present guidelines itself. Serotonin reuptake inhibitor ria were largely accounted for by the for screening, assessing, and treating antidepressants are the medications of emotional reactivity criteria and not depression in the context of brain choice. by the current or distressing recollec- injury. They also provide guidance Anxiety disorders tions or dreams of the event. regarding how to monitor andevaluate studies in PTSD treatment, andwhen to refer for formal The five major anxiety disorders des- have implicated the amygdala, hip-

VOL. 48 NO. 10, DECEMBER 2006 BC MEDICAL JOURNAL 511 Mild traumatic brain injury and psychiatric illness

SCREEN FOR DEPRESSION

Assessment of mood Not depressed: Record: •Supportive management pocampus, andother limbic structures. •presenting features suggesting • Be on alert for signs of Injury to these parts of the brain may depression developing depression •details of any previous history and actually predispose individuals to treatment developing PTSD or other anxiety dis- • assessment of mood using validated Severe depression or orders. measures complex presentation e.g. 9 •Suicidal Grados has recently reviewed the •Previous psychiatric diagnosis andtreatment of anxiety dis- history Mild to moderate depression orders following traumatic brain •Interfering with rehabilitation, not injury, particularly obsessive-compul- resolving spontaneously sive disorder. Much of the literature •Consider options for treatment, risk- benefit analysis revolves around case reports. Grados •Discuss alternatives with patient and family states that obsessive-compulsive phe- •Obtain informed consent/assent Psychiatric referral nomena following brain injury are probably more common than general- If antidepressants appropriate ly expected. Most symptoms have an early onset. Agree treatment plan following •Record baseline measures • Who will monitor and adjust treatment traumatic brain injury Psychosis more typically develops after severe brain injuries, but has START ANTIDEPRESSANT been reported after relatively mild traumatic brain injury. Arciniegas 10 and colleagues provide a full differ- Minimal or no Clinical review at 2–3 weeks Response* ential diagnosis for posttraumatic response psychosis as well as treatment guide- lines. Generally speaking, antipsy- Adjust to optimal Continue dose chotic medication should be pre- scribed, beginning with one-third to Formal review at 6–8 weeks one-half the starting dose usedin psy- Still minimal or Good Repeat measure chiatric patients who are not brain no response response Record change from baseline injured. 11 McAllister and Ferrell have noted a connection between the development DISCONTINUE TREATMENT CONTINUE TREATMENT of psychotic features and orbital Consider: Agree long-term treatment plan •Other antidepressant •Details of prescription frontal, temporal, and basal ganglion •Alternative treatment options •Recommended length of treatment and damage following mTBI. They also •Psychiatric referral end date provide a good set of treatment guide- •How treatment will be monitored •Who will be responsible for withdrawal lines. They recommendtreatment with the standard neuroleptic medications, Usually 4–6 months from start risperidone, olanzapine, and quetiap- ine. *Response to SSRIs is often seen WITHDRAWAL OF TREATMENT within 1–2 weeks of starting Personality change treatment, but TCAs may take •Repeat measure of depression longer to have effect. • Warn patient/family about rebound effects Alteration in personality is frequently •Graded withdrawal over 1–2 months reported by families as the most trou- blesome sequela of a brain injury. It is Figure. Use of antidepressant medication in adults following acquired brain injury.6 probable that changes in personality are part of the frontal lobe syndrome, Reproduced with permission of the Royal College of Physicians London. arising from direct damage to the

512 BC MEDICAL JOURNAL VOL. 48 NO. 10, DECEMBER 2006 Mild traumatic brain injury and psychiatric illness

frontal lobes. Disinhibited symptoms syndrome.” Concerta (methylphenidate) are the are frequently seen following damage The vast majority of individuals current medications of choice since to the orbital frontal area, disorganized with mild traumatic brain injury have they are taken once a day and last for syndromes following damage to the resolution of these symptoms by 3 12 hours, thereby enhancing compli- dorsal lateral region, andapathetic per- months. In a large study of concussed ance. sonalities following damage to the athletes, all subjects had total resolu- Sleep disturbance medial frontal region. Establishing tion of these symptoms by 3 months 13 change in personality following post- and in most cases by 7 days. Disturbances in sleeping are common- traumatic brain injury relies heavily Cognitive changes ly seen in both mood and anxiety dis- on collateral information from rela- orders. Furthermore, one of the most tives concerning how the patient was It is common to find individuals with common presentations following trau- prior to the injury. Patients them- changes in their cognitive abilities ma, particularly motor vehicle trau- selves may not have much insight into following traumatic brain injury. ma, is the development of pain leading subtle alterations in their personality. Changes are frequently reported with to sleep disorders and then resulting in These changes would be docu- attention, , and executive a mood disturbance. Poor sleep can DSM-IV-TR mented under the catego- function. Intelligence per se is rela- also negatively affect cognition, so ry “personality change due to a gener- tively resistant to brain trauma and is addressing problems with sleep is crit- DSM-IV- al and medical condition.” unlikely to be affected by mild trau- ically important in dealing with a TR lists a variety of subtypes, includ- matic brain injury. The role of the gen- patient with a brain injury. ing labile, disinhibited, aggressive, eral practitioner or psychiatrist is to There are no controlled trials deal- apathetic, paranoid, and mixed presen- identify cognitive changes andto make ing with sleep disorders following tations. an appropriate referral to a neuropsy- traumatic brain injury, so clinicians Individuals with alterations in per- chologist for documentation of these need to rely on treatment strategies sonality due to brain injury are rela- problems. derived from the study of sleep disor- tively resistant to treatment. Problems in attention following ders in general. Patients should be Postconcussion symptoms mild traumatic brain injury have re- advised to follow accepted rules of cently been described as “secondary sleep hygiene, such as going to bed There are a variety of symptoms fre- attention-deficit hyperactivity disor- and getting up at a specific time, quently seen in individuals who have der.” Specific instruments for measur- engaging in relatively vigorous exer- suffered or mTBI, in- ing attention following mTBI are not cise on a regular basis, and avoiding cluding fatigue, disordered sleep, fully developed. In the absence of bet- the use of coffee and other stimulants headache, dizziness, irritability or ter instruments, tools used for assess- later in the evening. The benzodi- aggression, affective lability, changes ing and diagnosing attention-deficit azepines and other sedative hypnotics in personality, and apathy or lack of hyperactivity disorder in children and such as zopiclone can help patients spontaneity. These features are refer- adults should be used if attentional sleep in the short term; however, for DSM-IV-TR enced in the discussion of problems are identifiedfollowing mild long-term treatment, particularly in postconcussion disorder, but the disor- traumatic brain injury. Affected indi- the presence of mood disorders, there der itself is not included as an official viduals may do poorly on the digit is better evidence supporting the use diagnosis because of insufficient infor- span of the Wechsler Intelligence of sedating antidepressants such as tra- mation to warrant it. Although these Scale for Children (WISC) or the zodone and amitriptyline. Melatonin, symptoms are frequently seen follow- Wechsler Adult Intelligence Scale an over-the-counter preparation cur- ing concussion or mildtraumatic brain (WAIS). rently available in British Columbia, injury, they are also common in the Treatment of inattention using has been known to be effective in a general population and in trauma vic- psychostimulants is increasingly rec- wide variety of sleep disorders. Doses tims who have not suffered brain dam- ognized as beneficial. Standard doses range from 1.5 to 24 mg. age or concussion. of methylphenidate and dextroamphet- General treatment A full discussion of this medical amine have been shown to benefit strategies controversy was recently reviewed by patients with attentional problems, 12 14 Rees, who recommends abandoning while the longer-acting preparations Lee andcolleagues have publishedon the term “persistent postconcussive Adderall-XR (dextroamphetamine) and the treatment of psychiatric disorders

VOL. 48 NO. 10, DECEMBER 2006 BC MEDICAL JOURNAL 513 Mild traumatic brain injury and psychiatric illness

Table. Psychotropics for treatment of psychiatric disorders secondary to brain injury. with lesions of the prefrontal cortex. Am J Psychiatry 2004:161:1247-1255. Target symptoms/diagnosis Medication 5. Levin HS, McCauley SR, Josic CP,et al. Predicting depression following mild Cognitive deficits • Dopaminergic agents • Psychostimulants traumatic brain injury. Arch Gen Psychia- • Cholinergic agents try 2005;62:523-528. 6. Turner-Stokes L, MacWalter R; Guideline Depressive disorders • Selective serotonin reuptake inhibitors • Tricyclic agents Development Group of the British Soci- • Other antidepressants ety of Rehabilitation Medicine; British Geriatrics Society; Royal College of • Anticonvulsants • Lithium carbonate Physicians London. Use of antidepres- sant medication following acquired brain Psychosis • Typical antipsychotics injury: Concise guidance. Clin Med • Atypical antipsychotics 2005;5:268-274. Anxiety disorders • Selective serotonin reuptake inhibitors 7. Sayal K, FordT,Pipe R. Case study: Bipo- • Tricyclic agents lar disorder after . J Am Acad • Buspirone Child Adolesc Psychiatry 2004;39:525- Apathy • Dopaminergic agents 528. • Psychostimulants 8. Hiott DW, Labbate L. Anxiety disorders Behavioral dyscontrol • Selective serotonin reuptake inhibitors associated with traumatic brain injuries. disorder • Tricyclic agents NeuroRehabilitation 2002;17:345-355. • Anticonvulsants 9. Grados M. Obsessive-compulsive disor- • Psychostimulants • Antipsychotics der after traumatic brain injury. Int Rev • Beta-blockers Psychiatry 2003;15:350-358. 10. Arciniegas DB, Harris SN, Brousseau KM. Psychosis following traumatic brain injury. Int Rev Psychiatry 2003;15:328- secondary to brain injury. They note ment in the first instance by the pri- 340. that there is a lack of research-based mary care physician. Many cases will 11. McAllisterTW, Ferrell RB. Evaluation and evidence in the brain-injured popula- necessitate a referral to a psychiatrist treatment of psychosis after traumatic tion. They do recommend, howev- for assessment and treatment. brain injury. NeuroRehabilitation 2000; er, that clinicians start low and go Competing interests 17:357-368. slow, that there be a continuous None declared. 12. Rees PM. Contemporary issues in mild reassessment of the clinical condition, traumatic brain injury. Arch Phys Med and that augmentation strategies be References Rehabil 2003;84:1885-1894. developed for partial response. They 1. Lishman WA. Organic Psychiatry: The 13. McCrea M, Guskiewicz KM, Marshall provide specific treatment guidelines Psychological Consequences of Cerebral SW,etal.Acuteeffectsandrecoverytime for all of the conditions discussed in Disorder. 3rd ed. Malden, MA: Blackwell following concussion in collegiate foot- this article. A summary of the medica- Science; 1998. 922 pp. ball players: The NCAA Concussion tions they recommend appears in the Table 2. Moldover J, Goldberg KB, Prout MF. Study. JAMA 2003;290:2556-2563 accompanying . Depression after traumatic brain injury: A 14. Lee HB, Lyketsos CG, Rao V. Pharmaco- Summary review of evidence for clinical hetero- logical management of the psychiatric geneity. Neuropsychol Rev 2004;14:143- aspects of traumatic brain injury. Int Rev Following mild traumatic brain 154. Psychiatry 2003;15:359-370. injury, there is an increased risk of 3. Jorge RE, Robinson RG, Moser D, et al. patients developing standard psychi- Major depression following traumatic atric disorders, specific alterations in brain injury. Arch Gen Psychiatry 2004; personality function, and cognitive 61:42-50. difficulties, particularly regarding 4. Mah L, Arnold MC, Grafman A. Impair- attention. All of these conditions ment of social perception associated require assessment and effective treat-

514 BC MEDICAL JOURNAL VOL. 48 NO. 10, DECEMBER 2006