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Mild Traumatic Brain Injury and Psychiatric Illness

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Mild Traumatic Brain Injury and Psychiatric Illness Derryck H. Smith, MD, FRCPC Mild traumatic brain injury and psychiatric illness Psychiatric illness, particularly depression, is common after brain injuries, 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 traumatic brain injury 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 anxiety 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 amnesia 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 • Apathy 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, social anxiety 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 memories associated with the trau- chiatric disorder, particular attention 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 cognition 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 Neuroimaging 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 Psychosis 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
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