Traumatic brain injury (TBI) is a public health epidemic. Approximately 2.8 million people sustain a TBI annually; of these, approximately 50,000 die, 282,000 are hospitalized, and 2.5 million are discharged from an emergency department.1 Mild TBI or concussion accounts for the majority of TBIs. Falls are the most common cause of TBI, followed by assault and motor vehicle accidents. According to recent statistics, during a 6-year period from 2007 to 2013, rates of TBI-related ER visits increased by 47%, but rates of hospitalization and death decreased by 2.5% and 5% respectively, underscoring the importance of managing TBI morbidity.1
Psychiatric disturbances are the most common long-term sequelae of TBI. In a recent article on the epidemiology and natural history of psychiatric disorders after TBI, Ponsford and colleagues2 noted that compared with the general population, patients with TBI have increased incidence of depressive disorder, anxiety disorder, and PTSD; depressive disorders are likely to be chronic and persistent.
In this article, we define TBI psychiatric disturbances as the development of psychiatric symptoms (emotional, behavioral, or cognitive) after the occurrence of a single or multiple TBIs. It may not always be possible to establish a causative link between TBI and the onset of psychiatric problems. When not possible, TBI should be considered as a treatment-informing medical comorbidity rather than an etiological factor.
Appropriate management of psychiatric disturbances can result in better outcomes, improved quality of life, and decreased societal impact. Management of TBI psychiatric disturbances should always be multidisciplinary and include both pharmacological and non-pharmacological interventions. An extensive armamentarium of pharmacological options is available, and there have been a number of randomized controlled trials and meta-analyses (Table).
TBI-associated depression. TBI-associated depression is characterized by prolonged, persistent sadness associated with other symptoms such as anhedonia, lack of motivation, decreased self-care, variable sleep and/or appetite pattern, feelings of hopelessness, and/or suicidal thoughts. These symptoms may last for a couple of weeks to months (major depressive episode) or persist in a milder form for two or more years (dysthymia).
SSRIs are often considered first-line agents because of their benign side effect profile. Sertraline, citalopram, and escitalopram are often favored because of their limited drug-drug interaction. Most clinical trials have focused on sertraline, but results have been inconsistent. In a trial comprising 15 patients with mild TBI 87% had a significant response and 67% achieved remission with sertraline.3 In a follow-up study of patients with TBI-associated depression no significant differences were seen between sertraline and placebo in depression severity, response, or remission rates.4 Similarly, Ashman and colleagues5 found no statistically significant difference between sertraline and placebo in a group of 52 patients with TBI-associated depression. However, the small sample size (N=11) and the high rate of discontinuations may have contributed to the lack of difference between the medication and placebo groups.
Dr Rao is Associate Professor, Department of Psychiatry and Behavioral Sciences and a member of the Miller Coulson Academy of Clinical Excellence, Johns Hopkins University, Baltimore, MD; Dr Vaishnavi is a Neuropsychiatrist, The Preston Robert Tisch Brain Tumor Center, Duke University. He is on the Faculty of Duke Institute for Brain Sciences, and Director, Transcranial Magnetic Stimulation and Director, Clinical Trials Carolina Partners, Durham, NC.
The authors report no conflicts of interest concerning the subject matter of this article.
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